Treatment of hepatitis delta virus infection

ABSTRACT

Methods of reducing hepatitis delta virus (HDV) viral loads in a patient are provided. In some embodiments, the method comprises treating the patient with lonafarnib-ritonavir co-therapy. In some embodiments, the method further comprises treating the patient with an interferon.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/996,147, filed Aug. 18, 2020, now U.S. Pat. No. 11,311,519, issuedApr. 26, 2022, which is a continuation of U.S. patent application Ser.No. 16/052,386, filed Aug. 1, 2018, now U.S. Pat. No. 10,828,283, issuedNov. 10, 2020, which is a continuation of U.S. patent application Ser.No. 15/335,327, filed Oct. 26, 2016, now U.S. Pat. No. 10,076,512,issued Sep. 18, 2018, which is a continuation-in-part of InternationalApplication No. PCT/US2015/028933, filed May 1, 2015, which claimspriority to U.S. Provisional Application Nos. 61/987,315, filed May 1,2014, 62/044,766, filed Sep. 2, 2014, 62/073,413, filed Oct. 31, 2014,and 62/151,349, filed Apr. 22, 2015, the contents of each of which areincorporated by reference herein. U.S. patent application Ser. No.15/335,327 also claims priority to U.S. Provisional Application Nos.62/251,026, filed Nov. 4, 2015, 62/297,740, filed Feb. 19, 2016, and62/321,623, filed Apr. 12, 2016, the contents of each of which areincorporated by reference herein. This application is also related toU.S. Provisional Application No. 62/150,721, filed Apr. 21, 2015, U.S.Provisional Application No. 62/153,815, filed Apr. 28, 2015, andInternational Application No. PCT/US2016/028651, filed Apr. 21, 2016,the contents of each of which are incorporated by reference herein.

FIELD OF INVENTION

The present invention provides methods for treating viral hepatitisresulting from hepatitis delta virus (HDV) infection, and so relates tothe fields of chemistry, medicinal chemistry, medicine, molecularbiology, and pharmacology.

BACKGROUND OF THE INVENTION

Hepatitis delta virus (HDV) causes the most severe form of viralhepatitis, and there is no effective medical therapy (see Lau, 1999,Hepatology 30:546-549). HDV always presents as a co-infection withhepatitis B virus (HBV), and a co-infected patient is much more likelyto die of complications of viral infection than a patient infected withHBV alone.

The HDV large delta antigen protein contains a CXXX box rendering it asubstrate for prenylation (see Zhang and Casey, 1996, Annu. Rev.Biochem. 65:241-269) by the prenyl lipid farnesyltransferase (see Glennet al., 1992, Science 256:1331-1333, and Otto and Casey, 1996, J. Biol.Chem. 271:4569-4572). Farnesylation of proteins catalyzed by FTase is anessential step in processing a variety of proteins and occurs bytransfer of the farnesyl group of farnesyl pyrophosphate to a cysteineat the C-terminal tetrapeptide of a protein in a structural motifsometimes referred to as the CAAX box. Further post-translationalmodifications of a farnesylated protein, including proteolytic cleavageat the cysteine residue of the CAAX box and methylation of the cysteinecarboxyl, generally follow farnesylation. Molecular genetic experimentsdemonstrated that specific mutation of the prenylation site in largedelta antigen prevents both its prenylation and HDV particle formation(see Glenn et al., 1992, supra; also see Glenn et al., 1998 J. Virol.72(11): 9303-9306; also see Bordier et al., 2002 J. Virol. 76(20):10465-10472. There continues to be an ongoing need for agents to treatHDV infection.

BRIEF SUMMARY OF THE INVENTION

In one aspect, methods are provided for treating hepatitis delta virus(HDV) infection by oral administration of lonafarnib in combination witha CYP3A4 inhibitor (e.g., ritonavir or cobicistat). In one aspect,methods are provided for treating HDV infection by oral administrationof lonafarnib at a dose of about 25 mg BID or 50 mg BID, in combinationwith ritonavir administered at 100 mg BID or 100 mg QD. In one aspect,methods are provided for treating HDV infection by oral administrationof lonafarnib at a dose of about 25 mg QD or BID, 50 mg QD or BID, orabout 75 mg QD or BID, in combination with ritonavir administered QD orBID at a therapeutically effective dose. In some embodiments, methodsare provided for treating HDV infection by oral administration oflonafarnib at a dose of about 25 mg QD or BID, 50 mg QD or BID, or about75 mg QD or BID, in combination with ritonavir administered QD or BID ata therapeutically effective dose and further in combination with aninterferon (e.g., unpegylated or pegylated interferon alpha orinterferon lambda) administered QW at a therapeutically effective dose.

In another aspect, methods of reducing HDV viral load in a human patientare provided. In some embodiments, the method comprises treating thepatient with lonafarnib-ritonavir co-therapy for at least 30 days. Insome embodiments, the patient has a chronic HDV infection. In someembodiments, the method comprises treating the patient with lonafarnib,ritonavir, and an interferon (e.g., unpegylated or pegylated interferonalpha or interferon lambda) for at least 30 days. In some embodiments,the method comprises treating the patient with lonafarnib-ritonavirco-therapy for at least 30 days, wherein the patient has a baselineviral load of at least 10⁵ IU/mL serum before the initiation oftreatment, and treatment results in a reduction of viral load to lessthan 10³ IU/mL serum.

In some embodiments, the method comprises administering (e.g., orallyadministering) lonafarnib at a daily dose in the range of 50 mg to 150mg. In some embodiments, lonafarnib is administered at a daily dose of50 mg. In some embodiments, lonafarnib is administered at a daily doseof 100 mg. In some embodiments, lonafarnib is administered at a dose of25 mg BID. In some embodiments, lonafarnib is administered at a dose of50 mg QD. In some embodiments, lonafarnib is administered at a dose of50 mg BID. In some embodiments, lonafarnib is administered at a dose of75 mg QD. In some embodiments, lonafarnib is administered at a dose of75 mg BID.

In some embodiments, the patient is treated with lonafarnib-ritonavirco-therapy for at least 60 days. In some embodiments, the patient istreated with lonafarnib-ritonavir co-therapy for at least 90 days. Insome embodiments, the patient is treated with lonafarnib-ritonavirco-therapy for at least one year.

In one embodiment the patient receiving lonafarnib-ritonavir co-therapyreceives lonafarnib at a daily dose of 50 mg/day to 150 mg/day, or at adaily dose of 50 mg/day to 100 mg/day, for example, 25 mg/day, 50mg/day, 75 mg/day, or 100 mg/day, preferably wherein each administrationof lonafarnib is no more than 75 mg, e.g., 25 mg or 50 mg; and ritonavirat a daily dose of 100 mg/day-200 mg/day, preferably wherein eachadministration of ritonavir is no more than 100 mg.

In one embodiment, the patient may receive 75 mg lonafarnib BID and 100mg ritonavir BID.

In one embodiment, the patient may receive 50 mg lonafarnib BID and 100mg ritonavir BID.

In one embodiment, the patient may receive 25 mg lonafarnib BID and 100mg ritonavir BID.

In one embodiment, the patient may receive 75 mg lonafarnib BID and 100mg ritonavir QD.

In one embodiment, the patient receives a daily dose of 100 mglonafarnib and 200 mg ritonavir. For example, the patient may receive 50mg lonafarnib BID and 100 mg ritonavir BID.

In one embodiment, the patient receives a daily dose of 75 mg lonafarniband 100 mg ritonavir. For example, the patient may receive 75 mglonafarnib QD and 100 mg ritonavir QD.

In one embodiment, the patient receives a daily dose of 50 mg lonafarniband 100 mg ritonavir. For example, the patient may receive 50 mglonafarnib QD and 100 mg ritonavir QD.

In one embodiment, the patient receives a daily dose of 50 mg lonafarniband 200 mg ritonavir. For example, the patient may receive 25 mglonafarnib BID and 100 mg ritonavir BID.

In some embodiments, in the treatment methods described herein, thelonafarnib and the ritonavir are administered together in a single unitdose form. In some embodiments, the unit dose form comprises amorphouslonafarnib. In some embodiments, the unit dose form comprises lonafarnib(e.g., amorphous lonafarnib), ritonavir, and a co-polymer. In someembodiments, the co-polymer is povidone.

In some embodiments, in the treatment methods described herein, thelonafarnib and the ritonavir are administered at about the same time asseparate unit dose forms.

In some embodiments, in the treatment methods described herein, thelonafarnib and the ritonavir are administered together in a liquidformulation containing both lonafarnib and ritonavir.

In one embodiment, the patient receives oral lonafarnib at a dose of 50mg/day, 75 mg/day, or 100 mg/day, administered BID or QD and oralritonavir at a daily dose of 100 mg/day administered BID or QD, forexample 100 mg/day, where the treatment results in a serum lonafarnibconcentration greater than 2,000 ng/mL, preferably greater than 4,000ng/mL, more preferably in the range of about 3,500 ng/mL to about 7,500ng/mL.

In one embodiment, the patient receives oral lonafarnib at a daily doseof 50 mg/day, 75 mg/day, or 100 mg/day, administered BID or QD,optionally with a boosting agent, where the treatment results in a serumlonafarnib concentration greater than 2,000 ng/mL, preferably greaterthan 4,000 ng/mL, more preferably in the range of about 3,500 ng/mL toabout 7,500 ng/m L.

In some embodiments, the patient has a baseline viral load of at least10⁴ HDV RNA copies per mL serum before treatment, and treatment resultsin a viral load of less than 10² HDV RNA copies per mL serum. In someembodiments, the patient has a baseline viral load of at least 10⁷ HDVRNA copies per mL serum before treatment, and treatment results in aviral load of less than 10⁵ HDV RNA copies per mL serum.

In some embodiments, wherein treatment results in a viral load of lessthan 10² HDV RNA copies per mL serum, the patient receives an additionalcourse of treatment of lonafarnib-ritonavir co-therapy for 30 days, andthe viral load remains at less than 10² HDV RNA copies per mL serumafter the additional course of treatment.

In some embodiments, the treatment further comprises administering aninterferon. In some embodiments, the interferon is interferon alpha orinterferon lambda. In some embodiments, the interferon is a pegylatedinterferon. In some embodiments, the interferon is pegylated interferonalpha-2a or pegylated interferon lambda-1a.

In some embodiments, lonafarnib and ritonavir or a similar boostingagent, optionally in combination with an interferon, are administered tothe patient in a course of therapy extending at least 30 days, moreoften at least 60 days or at least 90 days, even more often at least 120days, sometimes for at least 150 days, and sometimes for at least 180days. In some embodiments, lonafarnib and ritonavir or a similarboosting agent are administered to the patient in a course of therapyextending at least 6 months, at least 9 months, at least 12 months, atleast 15 months, at least 18 months, at least 24 months, or longer. Insome embodiments, dosing will be discontinued after virus levels havedecreased to below 3 log HDV RNA copies/mL (below 1,000 copies/mL) orbelow the level of detection for a period of time (such as 1 to 3 monthsor longer).

In some embodiments the therapeutic approaches disclosed herein resultin HDV RNA levels below 1,000 copies/mL serum or below 1,000 IU/mLserum, and in some cases may remain at the low level for at least onemonth. In some embodiments, after the HDV RNA level is determined to bebelow the threshold level (e.g., below 1,000 copies/mL serum or below1,000 IU/mL serum), the lonafarnib-ritonavir co-therapy is continued.

In some embodiments the therapeutic approaches disclosed herein resultin HDV RNA levels below 100 copies/mL serum or below 100 IU/mL serum andin some cases may remain at the low level for at least one month. Insome embodiments, after the HDV RNA level is determined to be below thethreshold level (e.g., below 100 copies/mL serum or below 100 IU/mLserum), the lonafarnib-ritonavir co-therapy is continued.

In some embodiments the therapeutic approaches disclosed herein resultin HDV RNA levels that are below the level of detection and in somecases may remain at the low level for at least one month. In someembodiments, after the HDV RNA level is determined to be below thethreshold level (e.g., below the level of detection), thelonafarnib-ritonavir co-therapy is continued.

In some embodiments the patient has a baseline viral load of at least10⁵ HDV RNA copies per mL serum before the initiation of treatment, andtreatment results in a reduction of viral load to less than 10² HDV RNAcopies per mL serum.

In some embodiments the patient has a baseline viral load of at least10⁵ IU/mL serum before the initiation of treatment, and treatmentresults in a reduction of viral load to less than 10² IU/mL serum.

In some embodiments, after the patient is determined to have a viralload of less than 10² HDV RNA copies per mL serum (or, alternatively,less than 10² IU/mL serum), treatment with lonafarnib-ritonavirco-therapy continues for at least 30 days.

In some embodiments, prior to the initiation of treatment, the patienthas a baseline viral load of at least 10² HDV RNA copies per mL serum(or, alternatively, less than 10² IU/mL serum), and treatment results ina viral load of less than 10⁵ HDV RNA copies per mL serum (or,alternatively, less than 10⁵ IU/mL serum).

In some embodiments, the therapeutic approaches disclosed hereincomprise administering lonafarnib at a first dose followed byadministering lonafarnib at a second dose, wherein the second dose islower than the first dose. In some embodiments, the therapeuticapproaches disclosed herein comprise an escalating dosage regimencomprising administering lonafarnib at a first dose for a firsttreatment period and then administering lonafarnib at a second dose thatis higher than the first dose for a second treatment period. In someembodiments, the patient receives lonafarnib at a first dose of 25 mgBID for the first treatment period followed by lonafarnib at a seconddose of 50 mg BID for the second treatment period. In some embodiments,the therapeutic approach comprises administering the lonafarnib at afirst dose for a first treatment period and then administeringlonafarnib at a second dose that is higher than the first dose for asecond treatment period if the patient does not experiences unacceptablegastrointestinal side effects during the first treatment period, oradministering the lonafarnib at a first dose for a first treatmentperiod and then administering lonafarnib at a second dose that is lowerthan the first dose for a second treatment period if the patientexperiences unacceptable gastrointestinal side effects during the firsttreatment period.

In another aspect, methods for inducing immune reactivation in a patientinfected with HDV and HBV are provided. In some embodiments, the methodcomprises administering lonafarnib at a total daily dose in the range of50 mg to 150 mg for at least 12 weeks and/or until a hepatitis flare isobserved. In some embodiments, the hepatitis flare is accompanied by atransient increase in the patient's HBV viral load. In some embodiments,the method comprises administering lonafarnib-ritonavir co-therapy inwhich ritonavir is administered at a total daily dose of 100-200 mg.Following immune reactivation, HDV viral load may be reduced by at least2 log, by at least 3 log, or reduced to an undetectable level.

In one embodiment, inducing immune reactivation in a patient infectedwith HDV and HBV involves administering lonafarnib at a first dosefollowed by administering lonafarnib at a second dose, wherein thesecond dose is lower than the first dose. For example, in some cases thefirst dose is administered for at least 8 weeks and the second dose isadministered for at least 2 weeks, and optionally at least 4 weeks. Insome cases the first dose of lonafarnib is 50 mg BID and the second doseof lonafarnib is 50 mg QD. In some cases the first dose of lonafarniband the second dose of lonafarnib are administered in combination withritonavir at a dose of 100 mg BID.

In another aspect, lonafarnib-ritonavir co-therapy, as described herein,is stopped after a period of from 10-24 weeks of treatment, andlonafarnib-ritonavir co-therapy is not administered to the patient forat least 4 weeks. In some embodiments, lonafarnib-ritonavir co-therapyis stopped after a period of 10 to 14 weeks of treatment, or thelonafarnib-ritonavir co-therapy is stopped at 12 weeks of treatment.

In some embodiments, the therapeutic approaches disclosed hereincomprise the step of detecting the occurrence of a hepatitis flare,and/or the step of detecting a transient increase of at least 3 log inthe patient's hepatitis B virus (HBV) viral load. In some embodiments,the hepatitis flare is characterized by an abrupt elevation of serumalanine aminotransferase (ALT) to a level over 200 U/L. In someembodiments, the hepatitis flare is characterized by an abrupt elevationof serum alanine aminotransferase (ALT) to a level over 800 U/L. In someembodiments, therapy is discontinued within 25 weeks (e.g., within 20weeks or within 12 weeks) following a hepatitis flare. In someembodiments, therapy is stopped at 12 weeks of treatment. In someembodiments, therapy is stopped after a period of 10 to 14 weeks oftreatment. In some embodiments, wherein the therapy is stopped after aperiod of treatment (e.g., after a period of from 10-24 weeks oftreatment, after a period of 10-14 weeks of treatment, or at 12 weeks oftreatment), the therapy (e.g., lonafarnib-ritonavir co-therapy) is notadministered to the patient for at least 4 weeks, e.g., at least 8weeks, at least 12 weeks, or longer. In some embodiments, therapy isstopped prior to detecting the occurrence of the hepatitis flare and/orprior to detecting the transient increase.

In yet another aspect, methods for reducing HBV viral load in a patientinfected with HBV and HDV are provided. In some embodiments, the patienthas a chronic HBV infection and the course of treatment results in areduction of the patient's HBV viral load compared to the baseline levelat the initiation of treatment. In one approach, the method involvesadministering lonafarnib at a total daily dose in the range of 50 mg to150 mg for at least 12 weeks, and optionally administering lonafarniband ritonavir, and detecting a reduction of at least 1 log in HBV viralload. In some cases treatment results in an at least 2 log reduction ofHBV viral load. In some cases the patient is not being treated withantiviral nucleotide or nucleoside analogs. In some embodiments, thepatient is also treated by administration of interferon, which may bepegylated interferon lambda, and which may be administered at a dose of120 mcg QW or 180 mcg QW.

In yet another aspect, a method of reducing hepatitis delta virus (HDV)viral load in a human patient with a chronic HDV infection, is provided,in which the patient receives lonafarnib-interferon co-therapy for atleast 30 days, where the co-therapy includes oral administration oflonafarnib at a total daily dose in the range of 50 mg to 150 mg andoral administration of interferon lambda-1a at a total weekly dose inthe range of 120 mcg to 180 mcg. Exemplary lonafarnib doses are 25 mgBID and 50 mg BID. In certain embodiments the interferon lambda-1a ispegylated interferon lambda-1a.

In one aspect, prior to the initiation of oral administration oflonafarnib and ritonavir, patient is prophylactically treated with atleast one, and typically a combination of at least two GI modifyingagents (one or more of an anti-emetic agent, an anti-diarrheal, and anantacid).

In another aspect, the GI modifying agents are administered at the sametime as lonafarnib and ritonavir, and lonafarnib is administered as adelayed release formulation, and does not release until after the GImodifying agents begin take effect.

In still another aspect, unit dose forms comprising lonafarnib andritonavir are provided. In some embodiments, the unit dose form isformulated for oral administration. In some embodiments, the unit doseform comprises lonafarnib and ritonavir in a ratio of about 1:2 (w/w) orabout 1:4 (w/w), wherein the unit dose form is formulated for oraladministration. In some embodiments, the unit dose form compriseslonafarnib in an amount from about 25 mg to about 100 mg and ritonavirin an amount of from about 50 mg to about 100 mg. In some embodiments,the unit dose form comprises amorphous lonafarnib. In some embodiments,the unit dose form comprises 25 mg amorphous lonafarnib and 100 mgritonavir. In some embodiments, the unit dose form comprises 50 mgamorphous lonafarnib and 100 mg ritonavir. In some embodiments, the unitdose form comprises an admixture of lonafarnib and ritonavir, amultiparticulate formulation, or a bilayer formulation. In someembodiments, the unit dose form further comprises a co-polymer. In someembodiments, the co-polymer is selected from the group consisting ofhydroxypropyl cellulose, hydroxypropyl methylcellulose, hypromellosephthalate, polyvinylpyrrolidone-vinylacetate copolymer,hypromellose-acetate-succinate, and mixtures thereof. In someembodiments, the co-polymer is not povidone. In some embodiments, theco-polymer is povidone. In some embodiments, the povidone is povidoneK30. In some embodiments, the unit dose form is formulated as a capsuleor a tablet. In some embodiments, one or both of the lonafarnib and theritonavir are formulated for immediate release. In some embodiments, oneor both of the lonafarnib and the ritonavir are formulated forcontrolled release.

In another aspect, liquid formulations comprising lonafarnib andritonavir are provided. In some embodiments, the liquid formulationcomprises lonafarnib and ritonavir at a ratio of 1:4 or 1:2.

In still another aspect, pharmaceutical packages comprising unit doseforms of lonafarnib and ritonavir are provided.

These and other aspects and embodiments of the invention are describedin more detail below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 . Time course of HDV RNA levels (copies/mL) in patients treatedwith 100 mg lonafarnib BID for 28 days. See Example 1.

FIG. 2 . Change in HDV RNA viral load, relative to serum levels oflonafarnib, in patients treated with 100 mg lonafarnib BID for 28 days.See Example 1.

FIG. 3 . HDV RNA viral titers in human patients treated with lonafarnibin doses of either 200 mg BID or 300 mg BID for a period of 28 days. SeeExample 2.

FIG. 4 . Changes in HDV RNA viral titers in patients treated withlonafarnib and interferon (Pegasys) at doses described in Example 3.

FIG. 5 . HDV RNA viral titers in patients treated with lonafarnib atdoses of 100 mg BID and ritonavir at 100 mg QD for a period of 28 days.See Example 4.

FIG. 6A-6C. Changes in HDV RNA viral titers. FIG. 6A graphicallyillustrates changes in HDV RNA viral titers from a normalized baselinein patients treated with lonafarnib and ritonavir at doses described inExample 5 for a period of 28 days. FIG. 6B graphically illustrateschanges in HDV RNA viral titers in patients treated with lonafarnib andritonavir at doses described in Example 5 for a period of 56 days. FIG.6C graphically illustrates changes in HDV RNA viral titers in patientstreated with lonafarnib and ritonavir at doses described in Example 5for a period of 84 days.

FIG. 7 . Inverse correlation between higher lonafarnib serum levels andHDV viral load in a patient administered 100 mg lonafarnib BID and 100mg ritonavir QD.

FIG. 8 . Reduced correlation between lower lonafarnib serum levels andHDV viral load in a patient administered 150 mg lonafarnib QD and 100 mgritonavir QD.

FIG. 9 . Relationship between lonafarnib serum concentration and changein viral load in patients administered 100 mg lonafarnib BID and 100 mgritonavir QD.

FIG. 10 . Changes in HDV RNA viral titers in patients treated withlonafarnib and a pegylated interferon or lonafarnib and ritonavir.

FIG. 11 . Changes in ALT values in patients treated with lonafarnib anda pegylated interferon.

FIG. 12 . Changes in HDV RNA viral titers in patients treated withlonafarnib, ritonavir and interferon using the combinations, doses, andschedule shown in the figure and described in Example 6.

FIG. 13 . Changes in HDV RNA viral titers in patients treated withlonafarnib, ritonavir and interferon using the combinations, doses, andschedule shown in the figure and described in Example 7.

FIG. 14 . Changes in HDV RNA viral titers in patients treated withlonafarnib, ritonavir and interferon using the combinations, doses, andschedule shown in the figure and described in Example 8.

FIG. 15A-15B. Changes in HDV RNA viral titers in patients treated withlonafarnib-ritonavir cotherapy with or without pegylated interferon-α asdescribed in Example 12. (A) Changes in HDV RNA viral titers measuredafter 4 weeks. (B) Changes in HDV RNA viral titers measured after 8weeks.

FIG. 16 . Changes in HDV RNA viral titers at various timepoints forpatients treated with lonafarnib-ritonavir cotherapy with or withoutpegylated interferon-α as described in Example 12.

FIG. 17 . Time course of HDV RNA levels (copies/mL) in patients treatedwith 50 mg BID lonafarnib and 100 mg BID ritonavir as described inExample 12.

FIG. 18 . Time course of HDV RNA levels (copies/mL) in patients treatedwith 50 mg BID lonafarnib, 100 mg BID ritonavir, and 180 mcg QWpegylated interferon-α as described in Example 12.

FIG. 19 . Time course of HDV RNA levels (copies/mL) in patients treatedwith 25 mg BID lonafarnib and 100 mg BID ritonavir as described inExample 12.

FIG. 20 . Time course of HDV RNA levels (copies/mL) in patients treatedwith 25 mg BID lonafarnib, 100 mg BID ritonavir, and 180 mcg QWpegylated interferon-α as described in Example 12.

FIG. 21 . Changes in ALT values at week 12 of treatment as described inExample 12.

FIG. 22 . Dose titration regimen through 24 weeks of treatment forlonafarnib/ritonavir co-therapy as described in Example 14. Ritonaviradjustments are not shown.

FIG. 23 . Changes in HDV RNA viral titers in patients treated withlonafarnib and ritonavir using the combinations, doses, and scheduleshown in the figure and described in Example 14.

FIG. 24 . Time course of HDV RNA levels (copies/mL) and ALT levels (U/L)in patients treated with lonafarnib/ritonavir co-therapy as described inExample 14.

FIG. 25 . Changes in ALT values at week 24 of treatment as described inExample 14.

FIG. 26 . Post-treatment ALT flare in patient A-001-5 treated with 200mg BID lonafarnib as described in Example 15, showing HDV-RNA negativityand ALT normalization following ALT flare and suppression of HDV RNA andHBV DNA. In FIGS. 26-30 , the limit of quantification (LOQ) for theassay for HDV is 3.2 log IU/mL and the LOQ for the assay for HBV is 2log IU/mL. Accordingly, for HDV, measurements graphed as >0 log and <3.2log should be considered indicative of the presence of HDV at aconcentration more than zero IU/mL and less than 3.2 log IU/mL, but arenot indicative of a precise quantity within this range. Likewise, forHBV, measurements graphed as >0 log and <2 log should be consideredindicative of the presence of HBV at a concentration more than zeroIU/mL and less than 2 log IU/mL, but are not indicative of a precisequantity within that range.

FIG. 27 . Post-treatment ALT flare in patient A-001-1 treated with 300mg BID lonafarnib as described in Example 15, showing HDV-RNA negativityand ALT normalization following ALT flare and suppression of HDV RNA andHBV DNA.

FIG. 28 . Post-treatment ALT flare in patient A-002-3 treated with 100mg BID lonafarnib in combination with 50 mg BID ritonavir for about 10weeks followed by lonafarnib (150 mg QD) and ritonavir (50 mg BID) for 2weeks, as described in Example 15, showing HDV-RNA negativity and ALTnormalization following ALT flare and HDV RNA and HBV DNA decline inparallel.

FIG. 29 . Post-treatment ALT flare in patient A-002-14 treated with 75mg BID lonafarnib in combination with 100 mg BID ritonavir for weeks1-12, 50 mg BID lonafarnib in combination with 100 mg BID ritonavir forweeks 13-24, and pegylated interferon alpha from weeks 16-24, asdescribed in Example 15, showing HDV-RNA and ALT decline following ALTflare and suppression of HDV RNA and HBV DNA.

FIG. 30 . Post-treatment ALT flare in patient A-002-23 treated with 50mg BID lonafarnib in combination with 100 mg BID ritonavir as describedin Example 15 showing HDV-RNA decline and ALT normalization followingALT flare and suppression of HDV RNA and HBV DNA.

FIG. 31 . Characteristic powder X-ray diffraction (XRPD) patterns ofritonavir-lonafarnib-povidone compositions at ratios of 1:1:2 (w/w),1:2:3 (w/w), and 1:1:5 (w/w), prepared as described in Example 16.

FIG. 32A-32B. Thermogravimetric analysis (TGA). (A) Characteristicpowder TGA thermogram of ritonavir-povidone (1:1) andritonavir-lonafarnib-povidone (1:1:2), (1:2:3), and (1:1:5)co-precipitates prepared as described in Example 16. (B) Characteristicpowder TGA thermogram comparing ritonavir-lonafarnib-povidone (1:1:2)and ritonavir-lonafarnib-HPMC (1:1:2) co-precipitates prepared asdescribed in Example 16.

DETAILED DESCRIPTION OF THE INVENTION

This detailed description of the invention is divided into sections forthe convenience of the reader. As will be apparent to those of skill inthe art upon reading this disclosure, each of the individual embodimentsdescribed and illustrated herein has discrete components and featureswhich may be readily separated from or combined with the features of anyof the other several embodiments (whether described in the same ordifferent sections of this disclosure) without departing from the scopeor spirit of the present disclosure. Any recited method can be carriedout in the order of events recited or in any other order that islogically possible. Embodiments of the present disclosure will employ,unless otherwise indicated, techniques of synthetic organic chemistry,biochemistry, biology, molecular biology, recombinant DNA techniques,pharmacology, and the like, which are within the skill of the art. Suchtechniques are explained fully in the literature. This disclosure is notlimited to particular embodiments described, and the embodiment of theinvention in practice may, of course, vary from that described herein.

I. Definitions

The terminology used herein is for the purpose of describing particularembodiments only, and is not intended to be limiting, because the scopeof the present invention will be limited only by the appended claims.Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. In this specification and inthe claims that follow, reference will be made to a number of terms thatshall be defined to have the following meanings unless a contraryintention is apparent. In some cases, terms with commonly understoodmeanings are defined herein for clarity and/or for ready reference, andthe inclusion of such definitions herein should not be construed asrepresenting a substantial difference over the definition of the term asgenerally understood in the art.

Although any methods and materials similar or equivalent to thosedescribed herein can be used in the practice or testing of the presentinvention, the preferred methods, devices, and materials are nowdescribed. All technical and patent publications cited herein areincorporated herein by reference in their entirety. Nothing herein is tobe construed as an admission that the invention is not entitled toantedate such disclosure by virtue of prior invention.

All numerical designations, e.g., pH, temperature, time, concentration,and molecular weight, including ranges, are approximations which arevaried (+) or (−) by increments of 0.1 or 1.0, as appropriate. It is tobe understood, although not always explicitly stated that all numericaldesignations are preceded by the term “about.”

HDV levels are generally presented using login units, following thenormal conventions of virology. HDV RNA levels may be presented in unitsof “RNA copies per mL” or as “International Units (IU) per mL.” See,Chudy et al., 2013, Collaborative Study to establish a World HealthOrganization International standard for hepatitis D virus RNA fornucleic acid amplification technique (NAT)-based assays.” WHO ExpertCommittee on Biological Standardization WHO/BS/2013.2227. Both units areused in this specification. As used herein, recitation of “HDV RNAcopies per mL,” (not including discussions related to clinical trialresults, e.g., as presented in the examples) should be read, forpurposes of written description or basis, as “HDV RNA copies/mL or HDVIU/mL.” Where a specific quantity of HDV RNA copies per mL is recited, amultiplier of 1.2 may be applied, for the purposes of writtendescription and support, to convert the quantity of HDV RNA copies/mL tothe quantity of IU/mL. For example, “120 HDV RNA copies per mL” shouldbe read as “120 copies/mL or 100 IU/mL.”

HBV DNA levels are generally described in the art using the IUconvention (see Saldanha et al., 2001, An international collaborativestudy to establish a World Health Organization international standardfor hepatitis B virus DNA nucleic acid amplification techniquesVoxSanguinis 80(1)63-71).

Changes in HDV RNA levels may be represented as a “log reduction”following the normal conventions of virology. For example, a 1 logreduction (i.e., −1 log) in viral load (e.g., from 7 log to 6 log) is a10-fold reduction, and a 2 log reduction (i.e., −2 log) in viral load(e.g., from 7 log to 5 log) is a 100-fold reduction. A reduction from 7log RNA copies/mL to 6 log RNA copies/mL is equivalent to a reductionfrom 7 log IU/mL to 6 log IU/mL. Changes in HBV DNA levels may describedusing the same terminology.

The singular forms “a,” “an,” and “the” include plural referents unlessthe context clearly dictates otherwise. Thus, for example, reference to“a compound” includes a plurality of compounds.

The term “administration” refers to introducing a compound, acomposition, or an agent of the present disclosure into a host, such asa human. One preferred route of administration of the agents is oraladministration. Other routes are intravenous administration andsubcutaneous administration.

“Anti-diarrheal agents” may be either of two types: Those that thickenthe stool and those that slow intestinal spasms. Thickening mixtures(such as psyllium) absorb water. This helps bulk up the stool and makeit more firm. Antispasmodic antidiarrheal products slow the spasms ofthe intestine by acting on the μ-opioid receptors in the myentericplexus of the large intestine. By decreasing the activity of themyenteric plexus, which in turn decreases the tone of the longitudinaland circular smooth muscles of the intestinal wall, the amount of timesubstances stay in the intestine increases, allowing for more water tobe absorbed out of the fecal matter. Anti-spasmodics also decreasecolonic mass movements and suppress the gastrocolic reflex.

The term “antacid” refers to agents that reduce, or reduce the effectsof, gastric acid secretion, and includes H2-Receptor antagonists andproton pump inhibitors.

The terms “baseline,” unless otherwise specified or apparent fromcontext, refers to a measurement (of, e.g., viral load, patientcondition, ALT level) made prior to a course of therapy.

The terms “BID” (twice a day), “QD” (once per day), “QW” (once perweek), and the like have their normal meaning in the medical arts.

The term “comprising” is intended to mean that the compounds,compositions and methods include the recited elements, but not excludingothers. “Consisting essentially of” when used to define compounds,compositions and methods, shall mean excluding other elements that wouldmaterially affect the basic and novel characteristics of the claimedinvention. “Consisting of” shall mean excluding any element, step, oringredient not specified in the claim. Embodiments defined by each ofthese transition terms are within the scope of this invention.

The terms “course of treatment” and “course of therapy” are usedinterchangeably herein, and refer to the medical interventions madeafter a patient is diagnosed, e.g., as being infected with HDV and inneed of medical intervention. Medical interventions include, withoutlimitation, the administration of drugs for a period of time, typically,for HDV infected patients, at least one and typically several or manymonths or even years.

The term “GI intolerance” refers to any one of diarrhea, nausea, andvomiting individually, or combinations thereof.

The terms “hepatitis flare,” “ALT flare” and “immune reactivation,” areused interchangeably and refer an abrupt elevation of serum alanineaminotransferase (ALT) to a level over two-fold baseline ALT in ahepatitis patient. In some embodiments, a hepatitis flare ischaracterized by an abrupt elevation of serum ALT to a level that isover five-fold the upper limit of normal (ULN). In some cases, the serumALT level is 200 U/L or higher. See, Liaw, Journal of Gastroenterologyand Hepatology, 2003, 18:246-252. Methods of measuring serum ALT levelsare known in the art. See, e.g., J. Clin. Chem. Clin. Biochem., 1986,24:481-495. In some embodiments, a hepatitis flare may be indicative oftherapeutic efficacy in an HDV patient receiving treatment withlonafarnib.

The term “HDV RNA viral load” or “viral load” of a human serum or plasmasample refers to the amount of HDV RNA in a given amount of a humanserum or plasma sample. HDV RNA is generally detected by quantitativereal-time reverse transcription-polymerase chain reaction (qRT-PCR)assays. In such assays, the amount of signal generated during the assayis proportional to the amount of HDV RNA in the sample. The signal fromthe test sample is compared to that of a dilution series of a quantifiedHepatitis Delta RNA standard, and a copy number of genome copies iscalculated. See, e.g., Kodani et al., 2013, J. Virol. Methods, 193(2),531; Karatayli et al., 2014, J. Clin. Virol, 60(1), 11. HDV RNA viralload may be reported as RNA copies per mL serum (or plasma) or usingInternational Units (IU) per mL serum (or plasma) (see Chudy et al.,2013, supra). A commercially available assay is available from ARUPLaboratories (Salt Lake City, Utah). The limit of detection for the ARUPHDV RNA assay has been reported to be 31 IU/mL. Analytik Jena AG(Germany) offers the RoboGene® HDV RNA Quantification Kit 2.0, which isCE-IVD certified with WHO standard references to assess the response toantiviral treatment. The limit of detection for the RoboGene® assay isreported to be 6 IU/mL. Reference to a “viral load” without specifiedunits (e.g., “a viral load of less than 100”) refers to copies of HDVRNA per mL serum, unless otherwise indicated or apparent from context.Unless otherwise specified, reference to below the level of detectionmeans below 6 IU/mL.

The term “HDV infection” with respect to a human (host) refers to thefact that the host is suffering from HDV infection. Typically, an HDVinfected human host will have a viral load of HDV RNA of at least about2 log HDV RNA copies/mL of host serum or plasma or 10² copies ofHDV-RNA/mL of host serum or plasma, often at least about 3 log HDV RNAcopies/mL of host serum or plasma or 10³ copies of HDV-RNA/mL of hostserum or plasma, and, often, especially for patients not on any therapy,at least about 4 log HDV RNA copies/mL of host serum or plasma or 10⁴copies of HDV-RNA/mL of host serum or plasma, such as about 4 log HDVRNA copies/mL of host serum or plasma to 8 log HDV RNA copies/mL of hostserum or plasma or 10⁴-10⁸ copies of HDV-RNA/mL of host serum or plasma.As used herein, the term “chronic HDV infection” with respect to a humanhost refers to an HDV infection that has persisted in the human host forat least 6 months, as documented by a positive HDV antibody (Ab) testand/or detectable HDV RNA by qRT-PCR. Diagnosis and pathogenesis of HDVis described, for example, in Wedemeyer et al., Nat. Rev. Gastroenterol.Hepatol, 2010, 7:31-40.

The term “HBV infection” refers to hepatitis B (HBV) infection. It willbe appreciated by a person of ordinary skill in the art that HDVinfection can only occur in individuals who are also infected with HBV.Thus, a human host having an HDV infection will also have an HBVinfection. Diagnosis of HBV infection can be based on the presence of anHBV serologic marker, such as hepatitis B surface antigen (HBsAg),hepatitis B core IgM antibody (anti-HBc IgM), and/or the presence of HBVDNA. Methods of detecting and quantifying HBV serologic markers and HBVDNA are described in the art. See, e.g., Liu et al., 2015, World JGastroenterol 21:11954-11963. In some embodiments, a human host havingan HDV infection and a HBV infection will have a HBV viral load of atleast about 2 log HBV DNA copies/mL of host serum or plasma or 10²copies of HBV-DNA/mL of host serum or plasma, often at least about 3 logHBV DNA copies/mL of host serum or plasma or 10³ copies of HBV-DNA/mL ofhost serum or plasma, or at least about 4 log HBV DNA copies/mL of hostserum or plasma or 10⁴ copies of HBV-DNA/mL of host serum or plasma.

The term “HBV viral load” of a human serum or plasma sample refers tothe number of copies of human HBV DNA in a given amount of human serumor plasma sample. HBV DNA may be detected and quantitated usingreal-time PCR. Commercial assays for quantitating HBV DNA are available.In the United States, Abbott offers the RealTime HBV assay, which is anin vitro PCR assay for the quantitation of HBV DNA in human serum orplasma. A CE certified kit for real-time PCR-based detection of HBV iscommercially available from Analytik Jena, Germany (RoboGene® HBV DNAQuantification Kit 2.0).

“H2-Receptor antagonists” are a class of drugs used to block the actionof histamine on parietal cells (specifically the histamine H2 receptors)in the stomach, decreasing the production of acid by these cells. H2antagonists are used in the treatment of dyspepsia.

“5-HT3 antagonists” are a class of drugs that act as receptorantagonists at the 5-HT3 receptor, a subtype of serotonin receptor foundin several critical sites involved in emesis, including vagal afferents,the solitary tract nucleus (STN), and the area postrema itself. The5-HT3 receptor antagonists suppress vomiting and nausea by inhibitingserotonin binding to the 5-HT3 receptors.

The term “lonafarnib” or “LNF” or “EBP994”, also known under the tradename Sarasar (Schering), refers to an FTase inhibitor4(2[4-[(11R)-3,10-dibromo-8-chloro-6,11-dihydro-5Hbenzo[5,6]-cyclohepta[1,2b]pyridin-11yl]-piperidino]-2-oxoethyl]-1-piperidinecarboxamide)(also identified as Sch-66336 or SCH 66336) having the structure shownbelow:

Lonafarnib is a crystalline solid with a melting point of approximately200° C. and is non-hygroscopic. Its molecular weight is 638.7. In thesolid state, the compound is thermally stable. In solution, it is stableat neutral pH but will hydrolyze in acidic or basic conditions. It is apoorly water soluble tricyclic compound, which when formulated incrystalline forms results in low and variable bioavailability inanimals. Considerable effort has been devoted to formulation developmentto improve the oral bioavailability. In addition to the drug substance,suitable pharmaceutical formulations of lonafarnib for administration incapsules contain povidone, poloxamer 188, croscarmellose sodium, silicondioxide, and magnesium stearate. The product is formulated with adrug:povidone (1:1) coprecipitate to achieve optimal bioavailability.These are safe and well tested excipients that are commonly used inmarketed products.

A patient is considered “HDV-RNA negative,” or, equivalently, “clearedof HDV,” when the quantity of HDV RNA per mL serum or plasma is belowthe limit of detection for the assay used (i.e., a qRT-PCR assay). Apatient is considered “persistently HDV-RNA negative” when the quantityof HDV RNA per mL serum or plasma is below the limit of detection in oneviral load measurement and remains below the limit of detection in asubsequent viral load measurement or measurements carried out over anextended period of time, such as at least 6 weeks, at least 12 weeks, atleast 24 weeks, at least 36 weeks, at least 48 weeks, or at least 1year. If not otherwise specified, a patient is considered “persistentlyHDV-RNA negative” if two viral load measurements at least 24 weeks apartdo not detect HDV virus and viral RNA is not detected in any interveningviral load measurement. It will be appreciated that measurements madefrom a serum sample may not detect the presence of low levels of virusin hepatocytes (“reservoir”). In many instances the presence of lowlevels will not give rise to any symptoms. In some instances a reservoirviral population may expand, causing the patient to relapse and requirefurther treatment.

“NK1” is a G protein-coupled receptor located in the central andperipheral nervous system. This receptor has a dominant ligand known asSubstance P (SP). SP is a neuropeptide, composed of 11 amino acids,which sends and receives impulses and messages from the brain. It isfound in high concentrations in the vomiting center of the brain, andresults in a vomiting reflux when activated. NK-1 receptor antagonistsblock signals given off by NK1 receptors.

The term “oral dosage form,” as used herein, refers to a dosage formthat is suitable for oral administration such as tablets, capsules, gelcaps, syrups, elixirs, and suspensions. “Solid oral dosage forms”include tablets, capsules, caplets, and the like.

The term “oral unit dosage form,” as used herein, refers to a unitdosage form that is intended to be orally administered.

The terms “patient”, “host,” or “subject,” are used interchangeably andrefer to a human infected with HDV, including patients previouslyinfected with HDV in whom virus has cleared.

The term “pharmaceutical composition” is meant to encompass acomposition suitable for administration to a subject. In general a“pharmaceutical composition” is sterile, and preferably free ofcontaminants that are capable of eliciting an undesirable responsewithin the subject (e.g., the compound(s) in the pharmaceuticalcomposition is pharmaceutical grade). Pharmaceutical compositions can bedesigned for administration to subjects or patients in need thereof viaa number of different routes of administration including oral,intravenous, buccal, rectal, parenteral, intraperitoneal, intradermal,intratracheal, intramuscular, subcutaneous, inhalational, and the like.

The terms “pharmaceutically acceptable excipient,” “pharmaceuticallyacceptable diluent,” “pharmaceutically acceptable carrier,” or“pharmaceutically acceptable adjuvant” means an excipient, diluent,carrier, and/or adjuvant that are useful in preparing a pharmaceuticalcomposition that are generally safe, non-toxic and neither biologicallynor otherwise undesirable, and include an excipient, diluent, carrier,and adjuvant that are acceptable for veterinary use and/or humanpharmaceutical use. “A pharmaceutically acceptable excipient, diluent,carrier and/or adjuvant” as used in the specification and claimsincludes one and more such excipients, diluents, carriers, andadjuvants. A wide variety of pharmaceutically acceptable excipients,such as vehicles, adjuvants, carriers or diluents, and auxiliarysubstances, such as pH adjusting and buffering agents, tonicityadjusting agents, stabilizers, wetting agents and the like, are known inthe art. Pharmaceutically acceptable excipients have been amplydescribed in a variety of publications, including, for example, A.Gennaro (2000) “Remington: The Science and Practice of Pharmacy,” 20thedition, Lippincott, Williams, & Wilkins; Pharmaceutical Dosage Formsand Drug Delivery Systems (1999) H. C. Ansel et al., eds., 7th ed.,Lippincott, Williams, & Wilkins; and Handbook of PharmaceuticalExcipients (2000) A. H. Kibbe et al., eds., 3rd ed. Amer. PharmaceuticalAssoc. For oral preparations, lonafarnib and/or ritonavir can be usedalone or in pharmaceutical formulations of the invention comprising, orconsisting essentially of, or consisting of lonafarnib in combinationwith appropriate additives to make tablets, powders, granules orcapsules, for example, with conventional additives, such as lactose,mannitol, corn starch or potato starch; with binders, such ascrystalline cellulose, cellulose derivatives, acacia, corn starch orgelatins; with disintegrators, such as corn starch, potato starch orsodium carboxymethylcellulose; with lubricants, such as talc ormagnesium stearate; and if desired, with diluents, buffering agents,moistening agents, preservatives and flavoring agents.

The term “pharmaceutically acceptable salt” refers to those salts thatretain the biological effectiveness and optionally other properties ofthe free bases and that are obtained by reaction with inorganic ororganic acids such as hydrochloric acid, hydrobromic acid, sulfuricacid, nitric acid, phosphoric acid, methanesulfonic acid, ethanesulfonicacid, p-toluenesulfonic acid, salicylic acid, malic acid, maleic acid,succinic acid, tartaric acid, citric acid, and the like. In the eventthat embodiments of the disclosed agents form salts, these salts arewithin the scope of the present disclosure. Reference to an agent of anyof the formulas herein is understood to include reference to saltsthereof, unless otherwise indicated.

As used herein, the term “polymer” refers to an organic substancecomposed of a plurality of repeating structural units (monomeric units)covalently linked to one another. The term “polymer” as used hereinencompasses organic and inorganic polymers. In some embodiments, apolymer is a compound of natural origin (e.g., protein-based polymerssuch as collagen, albumin, or gelatin, or polysaccharides such asalginate, cyclodextrin, dextran, agarose, chitosan, hyaluronic acid,starch, or cellulose). In some embodiments, a polymer is asemi-synthetic compound (e.g., cellulose derivatives). In someembodiments, a polymer is a synthetic compound (e.g., polyethyleneglycols, poloxamers, polylactides, acrylic acid polymers, orpolyamides). In some embodiments, a polymer is a natural biodegradablepolymer (e.g., albumin, collagen, gelatin, or starch). In someembodiments, a polymer is a synthetic biodegradable polymer (e.g.,polylactides, polyamides). In some embodiments, a polymer is anon-biodegradable polymer (e.g., polyethylenes, polymethylmethacrylates, polyvinyl pyrolidine, or cellulose derivatives).

“Proton pump inhibitors” are a class of antisecretory compounds thatsuppress gastric acid secretion by specific inhibition of the H+/K+ATPase enzyme system at the secretory surface of the gastric parietalcell. Because this enzyme system is regarded as the acid (proton) pumpwithin the gastric mucosa, inhibitors of this system have beencharacterized as a gastric acid-pump inhibitors in that they block thefinal step of acid production. This effect is dose-related and leads toinhibition of both basal and stimulated acid secretion irrespective ofthe stimulus.

The term “therapeutically effective amount” as used herein refers tothat amount of an embodiment of the agent (which may be referred to as acompound, an inhibitory agent, and/or a drug) being administered thatwill treat to some extent a disease, disorder, or condition, e.g.,relieve one or more of the symptoms of the disease, i.e., infection,being treated, and/or that amount that will prevent, to some extent, oneor more of the symptoms of the disease, i.e., infection, that thesubject being treated has or is at risk of developing.

The terms “treatment”, “treating”, and “treat” are defined as actingupon a disease, disorder, or condition with an agent to reduce orameliorate the pharmacologic and/or physiologic effects of the disease,disorder, or condition and/or its symptoms. “Treatment,” as used herein,covers any treatment of a disease in a human subject, and includes: (a)reducing the risk of occurrence of the disease in a subject determinedto be predisposed to the disease but not yet diagnosed as infected withthe disease, (b) impeding the development of the disease, and/or (c)relieving the disease, i.e., causing regression of the disease and/orrelieving one or more disease symptoms. “Treatment” is also meant toencompass delivery of an inhibiting agent to provide a pharmacologiceffect, even in the absence of a disease or condition. For example,“treatment” encompasses delivery of a disease or pathogen inhibitingagent that provides for enhanced or desirable effects in the subject(e.g., reduction of pathogen viral load, reduction of disease symptoms,etc.).

The term “undetectable,” as used with reference to HDV RNA levels, meansthat no HDV RNA copies can be detected by the assay methodologyemployed. In some embodiments, the assay is quantitative RT-PCR. Theterm “essentially undetectable,” as used with reference to HDV RNAlevels, means that fewer than 50 HDV RNA copies/mL serum or plasma canbe detected by the assay methodology employed (e.g., quantitativeRT-PCR), sometimes fewer than 25 HDV RNA copies/mL, sometimes fewer than10 HDV RNA copies/mL.

The term “unacceptable gastrointestinal side effects” refers togastrointestinal side effects that that prevent a patient fromcompleting a recommended course of therapy.

The term “unit dosage form,” as used herein, refers to physicallydiscrete units suitable as unitary dosages for human subjects, each unitcontaining a predetermined quantity of a compound (e.g., an anti-viralcompound and/or boosting agent, as described herein) or compounds,calculated in an amount sufficient to produce the desired treatmenteffect in association with a pharmaceutically acceptable diluent,carrier or vehicle.

All deuterated analogs (a compound is a deuterated analog of anothercompound, the “parent compound”, if it differs from the parent compoundby only replacement of one or more hydrogen atoms with one or moredeuterium atoms) of any active pharmaceutical ingredient describedherein, including without limitation, lonafarnib, and the boostingagents ritonavir and cobicistat, are, for purposes of the presentinvention, encompassed by reference to the parent compound.

All stereoisomers of any agent described herein, including withoutlimitation, lonafarnib, ritonavir, cobicistat, and any other activepharmaceutical agent described herein, such as those that may exist dueto asymmetric carbons on the various substituents, includingenantiomeric forms (which may exist even in the absence of asymmetriccarbons) and diastereomeric forms, are contemplated within the scope ofthis disclosure. Individual stereoisomers of the compounds of thedisclosure may, for example, be substantially free of other isomers, ormay be admixed, for example, as racemates or with all other, or otherselected, stereoisomers. The stereogenic centers of the compounds of thepresent disclosure can have the S or R configuration as defined by theIUPAC 1974 Recommendations.

II. Introduction

In one aspect, the present invention relates to treatment of patientsinfected with hepatitis D virus (HDV) by co-administering theprenyltransferase inhibitor lonafarnib and the CYP3A4 inhibitorritonavir. As is described herein below, it has been discovered thatalthough administration of lonafarnib at 100 mg BID for 28 days reducedviral load, the reduction was not sufficient for development as atherapeutic. Higher doses of lonafarnib were poorly tolerated andresulted in an unacceptable level of adverse events. Thus, whenadministered at 200 mg BID, serum levels of lonafarnib dropped afterabout one month of treatment, mostly likely due to poor tolerability,poor compliance by patients, and loss of agents that pass through the GItract. When administered at 300 mg BID, serum levels of lonafarnib werelower than expected, again, likely a result of poor tolerability. See,e.g., Table 11 below. Thus, while administration of lonafarnib at 100 mgBID was not sufficiently efficacious, higher doses were associated withsignificant GI-related adverse effects, rendering the treatmentunsuitable as routine therapies for patients infected with HDV.

The present invention relates in part to the discovery thatadministration of lonafarnib in combination with ritonavir(“lonafarnib-ritonavir cotherapy”) according to dose schedules describedherein is efficacious for treatment of HDV and results in superioroutcomes compared to lonafarnib monotherapy. Surprisingly,administration of 100 mg lonafarnib BID and 100 mg ritonavir QD resultedin higher serum concentrations of lonafarnib than observed withlonafarnib monotherapy measured after 56 days of treatment, but a lowerfrequency of adverse effects (see, e.g., Table 10 and Table 11 below).It has also been discovered that even lower doses of lonafarnib (e.g.,25 mg lonafarnib BID or 50 mg lonafarnib BID), administered incombination with ritonavir, are efficacious in reducing HDV RNA viralload and are better tolerated (see, e.g., FIG. 15A-B and Table 16below).

Further, it has been discovered that lonafarnib-ritonavir co-therapy maybe supplemented or combined with prophylactic administration of GImodifying agents (in particular prophylactic administration of one ormore of an anti-emetic agent, an anti-diarrheal, and an antacid) toimprove patient outcomes. Thus, one aspect of the invention relates tolonafarnib-ritonavir co-therapy combined with prophylacticadministration of a combination of GI modifying agents.

In one embodiment the patient receiving lonafarnib-ritonavir co-therapyreceives lonafarnib at a daily dose of 50-150 mg per day, for example 50mg per day, 75 mg per day, 100 mg per day, or 150 mg per day, andreceives ritonavir at a daily dose of 100-200 mg per day, for example100 mg per day or 200 mg per day. Certain aforementioned doses can beachieved by administering lonafarnib QD or BID and administeringritonavir QD or BID. Preferably, each administration of lonafarnib is nomore than 75 mg, e.g., no more than 50 mg, and each administration ofritonavir is no more than 100 mg. In one approach, lonafarnib isadministered BID and ritonavir is administered QD. In one approach bothlonafarnib and ritonavir are administered BID. In one approach bothlonafarnib and ritonavir are administered QD.

III. HDV Treatment

In one aspect, the present invention provides methods for treating HDVinfection, in which an HDV-infected patient is treated by oraladministration of lonafarnib and ritonavir (which may be referred to as“lonafarnib administration,” “lonafarnib-ritonavir co-therapy,” and thelike). In some embodiments, lonafarnib and ritonavir are administeredaccording to doses and dosing schedules described herein. In someembodiments, the HDV-infected patient receives prophylactic treatmentwith one, two, or three or more classes of gastrointestinal (GI)modifying agents. In some embodiments patients receivinglonafarnib-ritonavir co-therapy are also treated with interferon (e.g.,unpegylated or peygylated interferon-alpha or interferon-lambda).

Lonafarnib has been investigated for treatment of solid andhematological malignancies, Hutchinson-Gilford progeria syndrome, andchronic hepatitis delta virus infection, but is not approved for anyindication. The majority of reports concerning lonafarnib dosing arerelated to administration of lonafarnib to patients with cancer incombination with one or multiple antineoplastic agents.

Ritonavir (CAS Registry No. 155213-67-5), which is marketed under thetrade name Norvir® by AbbVie, Inc., has been administered as anantiretroviral agent, in combination with other antiviral agents, fortreatment of HIV-1 infected individuals. See Miller et al., 2015,Infection and Drug Resistance, 8:19-29. For treatment of HIV-1 in adultpatients, the recommended dosage of ritonavir is 600 mg twice daily bymouth to be taken with meals. See Norvir® package insert. Ritonavir hasalso been used as a pharmacologic enhancer or boosting agent.Pharmacokinetic “boosting” refers to the pharmacological enhancement oforally dosed drugs through the co-dosing with pharmacological enhancerswhich render these drugs more effective. Ritonavir has been used toboost the C_(max) of proteases used to treat HIV infection. The boostingeffect of ritonavir results from several properties of the drug.Ritonavir inhibits two key stages of metabolism.

First, ritonavir inhibits first-pass metabolism during absorption.Enterocytes that line the intestine contain both CYP3A4, one of the keycytochrome P450 isoenzymes associated with drug metabolism, andP-glycoprotein, an efflux transporter that can effectively pump drugsout of the gut wall and back into the intestinal lumen. Ritonavirinhibits both of these proteins. Consequently, co-administration ofritonavir and a drug transported by P-glycoprotein and/or metabolized byenterocyte CYP3A4 may increase the Cmax of the co-administered drug.Second, ritonavir inhibits CYP3A4 in the liver, thereby maintaining adrug's plasma half-life.

Several factors make it impossible to predict, and difficult todetermine, what an acceptable dose of ritonavir is for use as a boostingagent.

First, the boosting effects of ritonavir vary broadly and unpredictablydepending on the primary (i.e., co-administered) drug. This isillustrated by the Norvir® package insert (available at the FDA websitewww.rxabbvie.com/pdf/norvirtab_pi.pdf) which shows that the effect ofco-administration of ritonavir with a primary drug can range from a350-fold increase AUC of the primary drug (Fluticasone propionate,delivered as aqueous nasal spray) to an 11-fold increase (sidenafil) toa 1.2-fold increase (trimethoprim). There is also great variance evenwithin a single drug class. For example, in a meta-study of 17dose-ranging pharmacokinetic trials of protease inhibitors, Hill et al.evaluated the ritonavir boosting effect at doses of 50-800 mg daily withseven protease inhibitors: amprenavir, atazanavir, darunavir, indinavir,lopinavir, saquinavir and tipranavir. Hill concluded that ritonavir hasa dose-dependent boosting effect on Indinavir, tipranavir and lopinavir,but that the boosting effect of ritonavir on darunavir or saquinavir isnot correlated with its dose.

In addition, the pharmacokinetics of ritonavir in patients withhepatitis is likely more unpredictable relative to other treatmentpopulations. Li et al. reported that hepatic CYP3A4 expression isdown-regulated in individuals with chronic HBV infection. Although thesubpopulation of HBV-infected patients co-infected with HDV was notseparately studied, it is likely CYP3A4 down-regulation occurs in HDVpositive individuals. See Li et al., 2006, Zhonghua Yi Xue Za Zhi,86:2703-2706.

It has also been reported that ritonavir may inhibit P-glycoproteinfound in peripheral blood lymphocytes. See Lucia et al., 2001, J AcquirImmune Defic Syndr. 27:321-30. If lonafarnib is a substrate ofP-glycoprotein, the co-administration of ritonavir could cause lesslonafarnib to be transported back out of the cell, thereby increasingthe drug's intracellular half-life.

Further, the HDV patient subpopulation is characterized by higher levelsof cirrhosis (which develops in about 60 to 70% of patients with chronichepatitis D) than patients infected with HBV only. The pharmacokineticsof ritonavir in the HDV patient population is more unpredictablerelative to other populations with lower levels of or no cirrhosis.

The therapeutic effects of co-administration of lonafarnib and ritonavirto patients with chronic HDV were not known prior to the presentinvention, and nothing in the medical literature prior to the presentinvention described administration regimens (e.g., doses and dosescheduling) that are safe, tolerable, and effective for treating HDVpatients and patients with chronic HDV infection.

In addition, the side effect profiles of administration of lonafarniband co-administration of lonafarnib and ritonavir have not beenpreviously determined. Diarrhea, nausea, and vomiting are reported asside-effects of both lonafarnib administration (see, Schering I B) andritonavir administration (see Norvir Package Insert). In cancerpatients, a dose of 200 mg BID lonafarnib was characterized as “welltolerated.” See Hanrahan et al., 2009, “A phase II study of Lonafarnib(SCH66336) in patients with chemorefractory, advanced squamous cellcarcinoma of the head and neck,” Am J Clin Oncol. 32:274-279 (describinglonafarnib therapy following platinum-based therapy for recurrent SCCHN)and List et al., 2002, Blood, 100:789A (a lonafarnib dose of 200 mg BIDwas well tolerated in patients with advanced hematologic malignancies).However, the side-effect profile of administration of therapeuticallyeffective levels of lonafarnib to patients with chronic HDV infectionwas not known, and the side-effect profile of lonafarnib-ritonavirco-therapy was not known for any population.

Effect of Lonafarnib Administration on HDV Infection

As described below in Example 1, a cohort of patients with chronic deltahepatitis (HDV) received treatment with 100 mg lonafarnib BID for 28days and showed a mean change in HDV RNA levels from baseline to nadirof −0.74 log HDV RNA copies/mL, compared to −0.24 log HDV RNA copies/mLin patients receiving placebo. See also, Table 1 below. Plasma levels oflonafarnib ranged between 200 ng/mL and 1,100 ng/mL during treatment,and subjects with higher plasma levels of lonafarnib experienced greaterdeclines in HDV RNA titers during treatment. See FIG. 2 . However, amore robust reduction in viral load was desired.

As described in Example 2 below, administration of higher doses oflonafarnib to HDV-infected patients resulted in a more dramaticreduction of viral load but with unacceptable tolerability. In patientsreceiving 200 mg BID lonafarnib for 28 days the mean change in viralload was −1.63 log HDV RNA copies/mL. In patients receiving 300 mg BIDlonafarnib 28 days the mean change in viral load was −2.00 log HDV RNAcopies/mL. See also, Table 1 below.

Although daily administration of 200 or 300 mg BID lonafarnib providedsuperior viral load declines in HDV patients compared to a dailyadministration of 100 mg BID lonafarnib, administration of lonafarnib200 mg BID or 300 mg BID resulted in significant adverse effects, whichrenders these dosage regimens unsuitable for long term therapy.

Effect of Lonafarnib-Ritonavir Co-Administration on HDV Infection

As illustrated in Examples 4-6 and 12, below, lonafarnib-ritonavirco-therapy substantially reduced HDV viral load in patients at differentcombinations of doses. Example 4 describes the superior efficacyobserved with lonafarnib-ritonavir co-therapy as compared to lonafarnibmonotherapy. In patients receiving 100 mg BID lonafarnib in combinationwith 100 mg QD ritonavir for 28 days, the mean change in viral load was−2.2 log HDV RNA copies/mL. See also Table 1 below. Example 12demonstrates that comparable HDV RNA viral load decline was observed forpatients receiving 25 mg BID or 50 mg BID lonafarnib in combination with100 mg BID ritonavir as for patients receiving higher doses oflonafarnib in the lonafarnib-ritonavir co-therapy. Furthermore, in someinstances, lonafarnib-ritonavir co-therapy reduced HDV viral load toundetectable levels at week 8. See FIG. 5 and FIG. 17 . Thus, inaccordance with the invention, the use of lower doses of lonafarnib incombination with a boosting agent, alone or in combination with aninterferon, can enable patients to achieve significant therapeuticbenefit, with the lower lonafarnib dose in the range of 25 mg QD to 100mg BID, and preferred doses of 50 mg BID lonafarnib in combination with100 mg BID ritonavir.

TABLE 1 Change in Viral Load in Patients After 28 Days LonafarnibTherapy or Lonafarnib-Ritonavir Co-Therapy Mean Log Change in Serum HDVRNA at Day 28 N Placebo −0.24 4 Lonafarnib 100 mg BID* −0.74 6Lonafarnib 200 mg BID −1.63 6 Lonafarnib 300 mg BID −2.00 3 Lonafarnib100 mg BID −2.20 3 with Ritonavir 100 mg QD *Mean Plasma levels oflonafarnib ranged between 540 ng/mL and 890 ng/mL

Accordingly, in various methods of the invention, lonafarnib andritonavir each are administered in combination with the other orally ona continuous, daily basis, at least once per day (QD), and in variousembodiments two times per day (BID), to an HDV patient. In someembodiments, lonafarnib-ritonavir co-therapy is administered daily forat least 30 consecutive days. In some embodiments, lonafarnib-ritonavirco-therapy is administered daily for at least several months. In someembodiments, patients may receive lonafarnib-ritonavir co-therapy forthe rest of their lives.

As shown in FIG. 2 , HDV viral load declines with increasing serumconcentrations of lonafarnib. The correlation between lonafarnib serumlevels and viral load in patients receiving lonafarnib-ritonavirco-therapy is seen by comparing the viral load of a patient whomaintained a serum lonafarnib concentration in the range of about 3,500to 5,000 ng/mL for about 21 days (see FIG. 7 ) with the viral load of apatient who maintained a serum lonafarnib concentration in the range ofabout 1500 to 2500 ng/mL for about 21 days (see FIGS. 7 and 8 ), withthe former patient doing markedly better. See also Table 12, showingthat the patient with the highest lonafarnib serum level after fourweeks of co-therapy had the greatest decrease in viral load, and thatpatients with lonafarnib serum levels greater than 2,000 ng/mL had, ingeneral, more dramatic reductions in viral load than patients with serumlevels lower than 2,000 ng/mL (patient 4 is an exception to the trend).

Accordingly, in certain embodiments, lonafarnib and ritonavir areco-administered according to a schedule that results in serum lonafarniblevels greater than 2,000 ng/mL, for example, greater than 4,000 ng/mL.In some embodiments, lonafarnib and ritonavir are co-administeredaccording to a schedule that results in serum lonafarnib levels in therange of about 3,500 ng/mL to about 8,500 ng/mL (e.g., about 4,500 ng/mLto about 7,500 ng/mL, about 5,000 ng/mL to about 6,000 ng/mL, about5,500 ng/mL to about 6,500 ng/mL, about 6,000 ng/mL to about 7,000ng/mL, or about 6,500 ng/mL to about 7,500 ng/mL) or about 5,000 ng/mLto about 7,000 ng/mL.

As used herein, a serum lonafarnib level or concentration can bemeasured from a serum sample obtained from a subject periodically (suchas weekly, biweekly, monthly or according to other schedules) and thelevels during intervening periods can be extrapolated. For example, if ameasurement of 4,000 ng/mL is obtained at 4 weeks and a measurement of6,000 ng/mL is obtained at 6 weeks, for purposes of this analysis it isconcluded that the serum level during the intervening two weeks rangedbetween 4,000 and 6,000 ng/mL. In some embodiments the first measurementis made no earlier than one week after the initiation of oral therapy.

Serum levels of lonafarnib can be measured using art-known methods,including radioimmunoassays, chromatographic assays, mass spectrometryand the like. In some embodiments of the invention, patient serumsamples were extracted using a protein precipitation method(Acetonitrile). The samples were then loaded onto Waters CSH C18, 2.1×50mm, 1.7 μm column for separation, followed by LC-MS/MS in positive ionmode for detection of lonafarnib. The assay range for lonafarnib was1-2500 ng/mL.

Lonafarnib and Ritonavir Doses

In some embodiments, lonafarnib-ritonavir co-therapy comprisesadministering lonafarnib at a total daily dose in the range of 50 mg to150 mg (e.g., a total daily dose of about 50 mg, about 75 mg, about 100mg, about 125 mg, or about 150 mg) and administering ritonavir at atotal daily dose in the range of 100 mg to 200 mg (e.g., a total dailydose of about 100 mg, about 150 mg, or about 200 mg). In someembodiments, the total daily dose of lonafarnib is 50 mg and the totaldaily dose of ritonavir is 200 mg. In some embodiments, the total dailydose of lonafarnib is 100 mg and the total daily dose of ritonavir is200 mg. In some embodiments, the total daily dose of lonafarnib is 150mg and the total daily dose of ritonavir is 200 mg.

In some embodiments, lonafarnib is administered BID. In someembodiments, lonafarnib is administered QD. In some embodiments,lonafarnib is administered at a dose of 25 mg BID. In some embodiments,lonafarnib is administered at a dose of 50 mg BID. In some embodiments,lonafarnib is administered at a dose of 50 mg QD. In some embodiments,lonafarnib is administered at a dose of 75 mg BID. In some embodiments,lonafarnib is administered at a dose of 75 mg QD. In some embodiments,lonafarnib is administered at a dose of 100 mg QD.

In some embodiments, ritonavir is administered BID. In some embodiments,ritonavir is administered QD. In some embodiments, ritonavir isadministered at a dose of 100 mg BID. In some embodiments, ritonavir isadministered at a dose of 100 mg QD. In some embodiments, ritonavir isadministered at a dose of 75 mg BID. In some embodiments, ritonavir isadministered at a dose of 50 mg BID.

Exemplary doses, for illustration and not for limitation, are providedin Table 2 below. Usually, lonafarnib and ritonavir are administered(e.g., self-administered by the patient) together at about the same time(e.g., simultaneously or within about 15 minutes of each other).

TABLE 2 Embodiment 1 Embodiment 2 Embodiment 3 Embodiment 4 Doselonafarnib  75 mg BID  50 mg BID  75 mg BID  25 mg BID Dose ritonavir100 mg BID 100 mg BID 100 mg QD 100 mg BID Embodiment 5 Embodiment 6Embodiment 7 Embodiment 8 Dose lonafarnib  75 mg QD  50 mg QD  75 mg QD 50 mg QD Dose ritonavir 100 mg QD 100 mg QD 100 mg BID 100 mg BID

Each of Embodiments 1-8 in Table 2 may be administered with prophylacticGI modifying agents (e.g., an anti-emetic agent, an anti-diarrhealagent, and an antacid), and/or with an interferon (e.g., interferonalpha or interferon lambda). See, Section V and Section VI below.

In some embodiments, lonafarnib and ritonavir (or similar boostingagent, such as cobicistat) are administered to the patient, and both theritonavir dose and the lonafarnib dose are at least 50 mg QD or at least100 mg QD for at least 30 days, usually at least about 60 or even 90days or longer, including 6 months to a year or longer. In someembodiments, dosing will be discontinued after virus levels havedecreased to undetectable levels for a period of time (such as 1 to 3months or longer). In one approach suitable doses oflonafarnib/ritonavir include for least for 30 days, more often at least60 days, and typically at least 90 days, or longer than 90 days. In oneapproach treatment of hepatitis delta virus (HDV) infection in a humaninvolves administering a daily dose of about 50 mg/day, about 100mg/day, or about 150 mg/day of lonafarnib (e.g., about 25 mg BID, about50 mg BID, about 50 mg QD, about 75 mg BID, about 75 mg QD, or about 100mg QD of lonafarnib), and a therapeutically effective amount of a CYP3A4inhibitor (e.g., ritonavir or cobicistat) for at least about 30 days,thereby treating the HDV infection. In one approach ritonavir is dosedat 100 mg QD.

In some embodiments, treatment with lonafarnib-ritonavir co-therapyresults in a serum lonafarnib concentration that is greater than 2,000ng/mL when measured after 4 weeks of treatment. In some embodiments,treatment with lonafarnib-ritonavir co-therapy results in a serumlonafarnib concentration that is greater than 3,000 ng/mL when measuredafter 4 weeks of treatment.

Patient Population

In some embodiments, a patient to be treated with a co-therapy describedherein is a patient having a chronic HDV infection. In some embodiments,the patient to be treated has a chronic HDV infection of at least 6months duration documented by a positive HDV antibody (Ab) test, and/ordetectable HDV RNA by qRT-PCR. In some embodiments, a patient to betreated with a co-therapy method described herein is a patient having anacute HDV infection, one that is newly diagnosed or otherwise believednot to have existed in the patient for more than six months. Diagnosisand pathogenesis of HDV is described, for example, in Wedemeyer et al.,Nat. Rev. Gastroenterol. Hepatol, 2010, 7:31-40. HDV is known to existin a variety of subtypes; the methods described herein are suitable fortreating all HDV patients, regardless of HDV subtype.

In some embodiments, a patient to be treated has a baseline viral loadof at least 10⁴ HDV RNA copies per mL serum, e.g., at least 10⁵ HDV RNAcopies per mL serum or plasma, at least 10⁶ HDV RNA copies per mL serumor plasma, at least 10⁷ HDV RNA copies per mL serum or plasma, or atleast 10⁸ HDV RNA copies per mL serum or plasma. In some embodiments,HDV viral load is measured using serum samples from the patient. In someembodiments, HDV viral load is measured using plasma samples from thepatient. In some embodiments, viral load is measured by quantitativeRT-PCR. qRT-PCR assays for quantification of HDV RNA in serum or plasmaare known in the art, e.g., as described above.

In some embodiments, a patient to be treated exhibits one or moresymptoms of liver dysfunction. In some embodiments, the patient exhibitsone or more liver function parameters that are outside the normalparameters for a healthy control (e.g., a subject that is not infectedwith HDV or HBV). In some embodiments, the liver function parameter isselected from the group consisting of serum albumin, bilirubin, alanineaminotransferase (ALT), aspartate aminotransferase (AST), andprothrombin activity. In some embodiments, the patient has a serum ALTlevel that is at least two-fold higher than the upper limit of normal(ULN) (e.g., at least 2-fold, at least 3-fold, at least 4-fold, at least5-fold, at least 6-fold, at least 7-fold, at least 8-fold or higher thanthe ULN). Liver function parameters are described in the art. See, e.g.,Limdi et al., Postgrad Med J, 2003, 79:307-312. Methods of measuringthese liver function parameters are known in the art and are alsocommercially available.

Dose Escalation and Dose Reduction

In one embodiment the patient being treated for HDV infection receivesan escalating dosage regimen of lonafarnib, in that one or more laterdoses is a larger dose than one or more earlier doses. In someembodiments, an escalating dosage regimen may increase the patient'stolerance to the drug and minimize side effects. In some embodiments,dose escalation comprises administering lonafarnib at a first dose for afirst treatment period followed by administering lonafarnib at a seconddose that is higher than the first dose for a second treatment period.In some embodiments, the length of time for the first treatment periodis the same as the length of time for the second treatment period. Insome embodiments, the first treatment period and the second treatmentperiod are different lengths of time. In some embodiments, doseescalation further comprises administering one or more additional dosesof lonafarnib for one or more additional treatment periods.

In some embodiments, the duration of the administration of each dosagein the escalating regimen is within 1-4 weeks. The duration of eachdosage may be adjusted (e.g., accelerated) by a clinician based on thepatient's response. For example, without limitation, a patient may begiven lonafarnib 25 mg BID for an initial two-week period, followed by50 mg BID for a second two-week period until a predetermined desiredfinal dose is reached. Typically the escalating doses areco-administered with ritonavir at a suitable dose, for example, 100 mgQD or BID. Dose escalation may continue to 75 mg BID or higher (e.g., 75mg BID), including 100 mg BID and higher (e.g., 100 mg BID).

In some embodiments, the lonafarnib-ritonavir co-therapy comprisesadministering the lonafarnib at a first dose for a first treatmentperiod and then administering lonafarnib at a second dose that is higherthan the first dose for a second treatment period if the patient doesnot experience unacceptable gastrointestinal side effects during thefirst treatment period. As a non-limiting example, in some embodiments,lonafarnib is administered at a first dose of 50 mg BID for a firsttreatment period, and if the patient does not experience unacceptablegastrointestinal side effects during the first treatment period, thepatient is administered a second dose of 75 mg BID for a secondtreatment period.

In some embodiments, the lonafarnib-ritonavir co-therapy comprisesadministering the lonafarnib at a first dose for a first treatmentperiod and then administering lonafarnib at a second dose that is lowerthan the first dose for a second treatment period if the patientexperiences unacceptable gastrointestinal side effects during the firsttreatment period. As a non-limiting example, in some embodiments,lonafarnib is administered at a first dose of 75 mg BID for a firsttreatment period, and if the patient experiences unacceptablegastrointestinal side effects during the first treatment period, thepatient is administered a second dose of 50 mg BID for a secondtreatment period.

Duration of Treatment, Induction of Immunologic Reactivation, andTreatment Endpoints

Patients may receive lonafarnib-ritonavir co-therapy for a predeterminedtime, an indefinite time, or until an endpoint is reached. Treatment maybe continued on a continuous daily basis for at least two to threemonths. Therapy is typically for at least 30 days or one month, moreoften at least 60 days or two months, or at least 90 days or threemonths, even more often at least 120 days or four months, sometimes forat least 150 days or five months, and sometimes for at least 180 days orsix months. In some embodiments, treatment is continued for at least sixmonths to one year. In other embodiments, treatment is continued for therest of the patient's life or until administration is no longereffective in maintaining the virus at a sufficiently low level toprovide meaningful therapeutic benefit.

In accordance with the methods of the invention, some HDV patients willrespond to co-therapy herein by clearing virus to undetectable levels,often after experiencing a hepatitis flare, after which treatment may besuspended unless and until the HDV levels return to detectable levels.Other patients will experience a reduction in viral load and improvementof symptoms but will not clear the virus to undetectable levels but willremain on “long term therapy” for so long as it provides therapeuticbenefit.

In some cases, a patient is treated to a specified endpoint (e.g., aviral load less than 10² or 10³; a hepatitis flare; or clearance ofvirus) in a first course of treatment. When the patient has achieved theendpoint, the medical provider may elect to discontinue therapy, e.g.,lonafarnib-ritonavir co-therapy. Alternatively, when the patient hasachieved the endpoint, the medical provider may elect to continuetherapy, e.g., lonafarnib-ritonavir co-therapy. For convenience thepost-endpoint therapy is sometimes referred to as a “second (or“additional”) course of treatment.” The first and second courses oftherapy may (and typically do) comprise administration of the samedosage regimen (i.e., the same dose and frequency of administration).For avoidance of doubt, although the terminology is sometimesconvenient, a patient may receive a “single course of treatment” thatextends through an endpoint.

In some embodiments, the patient receiving lonafarnib-ritonavirco-therapy has a baseline viral load of at least 10⁴ HDV RNA copies permL serum, and treatment results in a viral load of less than 10² HDV RNAcopies per mL serum. In some embodiments, a patient having a baselineviral load of at least 10⁴ HDV RNA copies per mL serum receives a firstcourse of treatment that results in a viral load of less than 10² HDVRNA copies per mL serum, and subsequently receives an additional courseof treatment, wherein the viral load remains at less than 10² HDV RNAcopies per mL serum after the additional course of treatment. In someembodiments, treatment results in an HDV viral load below the level ofdetection.

In some embodiments, the patient receiving lonafarnib-ritonavirco-therapy has a baseline viral load of at least 10⁵ HDV RNA copies permL serum, and treatment results in a viral load of less than 10³ HDV RNAcopies per mL serum. In some embodiments, a patient having a baselineviral load of at least 10⁵ HDV RNA copies per mL serum receives a firstcourse of treatment that results in a viral load of less than 10³ HDVRNA copies per mL serum, and subsequently receives an additional courseof treatment, wherein the viral load remains at less than 10³ HDV RNAcopies per mL serum after the additional course of treatment. In someembodiments, the patient receiving lonafarnib-ritonavir co-therapy has abaseline viral load of at least 10⁵ HDV RNA copies per mL serum, andtreatment results in a viral load of less than 10² HDV RNA copies per mLserum. In some embodiments, treatment results in an HDV viral load belowthe level of detection.

In some embodiments, the patient receiving lonafarnib-ritonavirco-therapy has a baseline viral load of at least 10⁶ HDV RNA copies permL serum, and treatment results in a reduced viral load of less than 10⁴HDV RNA copies per mL serum, less than 10³ HDV RNA, or less than 10² HDVRNA. In some embodiments, the patient receiving lonafarnib-ritonavirco-therapy has a baseline viral load of at least 10⁷ HDV RNA copies permL serum, and treatment results in a reduced viral load of less than 10⁵HDV RNA copies per mL serum, less than 10⁴ HDV RNA, or less than 10³ HDVRNA, or less than 10² HDV RNA. In some embodiments, treatment results inan HDV viral load below the level of detection.

In some embodiments, treatment with lonafarnib-ritonavir co-therapyresults in a reduction of HDV viral load in the patient of at least 1.5log HDV RNA copies/mL serum when measured after 8 weeks of treatment. Insome embodiments, treatment with lonafarnib-ritonavir co-therapy resultsin a reduction of HDV viral load in the patient of at least 2.0 log HDVRNA copies/mL serum when measured after 8 weeks of treatment. In someembodiments, treatment with lonafarnib-ritonavir co-therapy results in areduction of HDV viral load in the patient of at least 2.5 log HDV RNAcopies/mL serum when measured after 8 weeks of treatment.

In some embodiments, treatment with lonafarnib-ritonavir co-therapyresults in a reduction of HDV viral load in the patient of at least −1log, or at least −2 log, or at least −3 log or at least −5 log, or atleast −6 log when measured a number or weeks (e.g. 12, 24, 36, 48, 60,72 or 90 weeks after the initiation of treatment.

In some embodiments, treatment with lonafarnib-ritonavir co-therapyresults in a sustained reduction in HDV RNA levels. For example, in someembodiments, treatment results in a decrease in the level of HDV RNA inthe patient's serum or plasma, and this decreased level is sustained fora period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months,1 year, or longer). In some embodiments, a decreased level of HDV RNA issustained for a period of time (e.g., 1 month, 3 months, 1 year orlonger) after a course of treatment is finished. In some embodiments, adecreased level of HDV RNA is sustained for a period of time (e.g., 1month, 3 months, 1 year or longer) while a course of treatment is stillongoing. In some embodiments, the course of treatment results in HDV RNAlevels (e.g., serum HDV RNA levels or plasma HDV RNA levels) below 1,000copies/mL. In some embodiments, the HDV RNA levels remain below 1,000copies/mL for at least one month, at least three months, at least oneyear, or longer. In some embodiments, the course of treatment results inHDV RNA levels (e.g., serum HDV RNA levels or plasma HDV RNA levels)below 100 copies/mL. In some embodiments, the HDV RNA levels remainbelow 100 copies/mL for at least one month, at least three months, atleast one year, or longer. The phrase “remains below” an initialmeasured value (e.g., 100 copies/mL or 100 IU/mL) for 1 month (oranother specified time) means that a viral load measurement taken atleast 1 month (or at another specified time) after determination of theinitial measured value is no higher than the initial value. In someembodiments, the patient does not receive lonafarnib orlonafarnib-ritonavir co-therapy during the specified time. In someembodiments, the patient does not receive any anti-HDV treatment duringthe specified time.

In some embodiments, therapy as disclosed herein is continued for aperiod of time until HDV RNA levels are below 3 log HDV RNA copies/mL(below 1,000 copies/mL), or sometimes until HDV RNA levels are below 2log HDV RNA copies/mL (below 100 copies/mL) or below the level ofdetection. In some cases therapy may be continued for a period of time(such as 1 to 3 months or longer) after viral load has dropped toacceptably low levels (e.g., undetectable levels). In some embodiments,therapy is continued until the HDV viral load is reduced to undetectablelevels.

In some cases, therapy is continued until a “hepatitis flare” or “ALTflare” is observed in the patient. Hepatitis flares (or acuteexacerbations) are an abrupt elevation of serum alanine aminotransferase(ALT) over fivefold the upper limit of normal, about 40 U/L, observed inchronic hepatitis B virus (HBV) infection. HBV flares in HBV patientsresult from an HLA-I restricted, cytotoxic T lymphocyte (CTL)-mediatedimmune response against HBV and its downstream mechanisms. Higher ALTlevels reflect a more robust immune clearance of HBV. See Liaw, 2003,“Hepatitis flares and hepatitis B e antigen seroconversion: implicationin anti-hepatitis B virus therapy,” J Gastroenterol Hepatol 18:246-52.Hepatitis flares have not previously been reported in response toanti-HDV treatment, but indications of flares have been observed inresponse to the lonafarnib-ritonavir cotherapy described herein. Forexample, two patients who received orally administered lonafarnib 100 mgBID and ritonavir 50 mg BID for 12 weeks exhibited ALT flarescharacterized by ALT levels 10-20 fold higher than a normal individual.ALT flares were also observed in some patients receiving lonafarnib 200mg BID or 300 mg BID monotherapy, as well as in patients receiving lowerdoses of lonafarnib in lonafarnib-ritonavir co-therapy (e.g., 75 mg BIDlonafarnib in combination with 100 mg BID ritonavir, and 50 mg BIDlonafarnib in combination with 100 mg BID ritonavir. See Example 15below.

The observation of flares in HDV patients suggests that co-therapy withritonavir and lonafarnib at dosages described herein may have anunprecedented beneficial therapeutic effect in clearing HDV from thepatient. Without being bound to a particular theory or mechanism, it isbelieved that in at least a subset of HDV patients, treatment withlonafarnib or with lonafarnib-ritonavir co-therapy results in areactivation of the immune system that had been suppressed as a resultof infection with HDV virus. Concomitant HBV/HDV infection often resultsin suppression of HBV replication in human patients and, in at least asubset of HDV patients, suppression of HDV infection using methodsdescribed herein results in at least a transient increase in HBV levels.Without being bound to a particular theory, it is also believed that HDVsuppresses a patient's immune response in parallel with suppressing HBV;suppression of HDV by lonafarnib treatment releases the suppression ofHBV and HBV replication increases. It has been found that some patientswho experience immunologic reactivation and who are not receiving anyanti-HBV therapy (e.g., antiviral nucleotide or nucleoside analogs)typically exhibit a transient increase of at least 3 log in HBV DNAlevels within about 12 weeks from the onset of treatment. See, e.g.,Example 15, below. According to the invention, the increase in HBV maybe used as a surrogate marker to monitor the extent of immunologicreactivation in response to treatment (e.g., the efficacy of anti-HDVtreatment). The ALT flares that are observed in at least a subset of HDVpatients in response to HDV treatment, for example as described inExample 15 below, are indicative of a reactivated immune response.Without intending to be bound by a particular mechanism, it is believedthat upon immunologic reactivation, the immune system begins to respondto and clear the HDV infection, resulting in the release of ALT fromtargeted HDV-infected hepatocytes that manifests as an ALT flare.Additionally, for at least some patients, immunologic reactivation canresult in a reduction in HBV levels or clearance of HBV infection. Asdescribed in Example 15 below, patients from a variety of lonafarnibtreatment cohorts who exhibited ALT flares subsequently exhibitedsuppression or clearance of the HDV infection and a suppression in HBVDNA levels. Without being bound to a particular theory, it is believedthat in patients experiencing immunologic reactivation, as evidenced bythe presence of ALT flares, suppression of HBV is due at least in partto an immune-mediated response. Thus, while prior to LNF treatment HBVis often suppressed by the HDV, after immunologic reactivation hasresulted in suppression or clearance of the HDV, the observed continuedor even more pronounced suppression of HBV reflects the newly improvedimmune-mediated response against HBV.

As described in Example 15 below, it has been found that patients whoexperience immunologic reactivation exhibit certain characteristics withrespect to HDV RNA levels and HBV DNA levels. For example, patients whoexperience immunologic reactivation typically exhibit a decrease in HDVRNA levels (e.g., of at least 1 log) within the first two weeks oftreatment, after which the decreased HDV RNA level is sustained (if notfurther reduced) for at least another two weeks, before an increase inHDV levels of at least 50% or more from the nadir. In some embodiments,a patient who experiences immunologic reactivation exhibits a transientincrease of at least 3 log in HBV viral load.

In some embodiments, the method of inducing immunologic reactivation inthe patient comprises administering lonafarnib or lonafarnib-ritonavirco-therapy in a first course of treatment at a first dose, followed byadministering lonafarnib or lonafarnib-ritonavir co-therapy in a secondcourse of treatment at a second dose, wherein the second dose isdifferent from the first dose. In some embodiments the second dose is alower lonafarnib dose (a “step-down”). In some embodiments, the firstcourse of treatment is in the range of about 4-12 weeks, e.g., about8-12 weeks. In some embodiments, the second course of treatment is about2-4 weeks. In some embodiments, the first course of treatment is about 8weeks and the second course of treatment is about 4 weeks.

In some embodiments, within about 12-24 weeks after the occurrence of anALT flare, the patient is HDV-RNA negative. In some embodiments, withinabout 12-24 weeks after the occurrence of an ALT flare, the patient hasnormalized ALT levels (i.e., an ALT level that is within the upper limitof normal as defined in the art). In some embodiments, following theimmune reactivation the patient's HDV viral load is reduced by at least3 log compared to the patient's baseline level at the initiation oftreatment. In some embodiments, following the immune reactivation thepatient's HBV viral load is reduced by at least 2 log compared to thepatient's baseline level at the initiation of treatment. In someembodiments, the patient's HDV viral load and/or HBV viral load isreduced to an undetectable level.

In some embodiments, treatment with lonafarnib-ritonavir co-therapyresults in improved liver function in the patient. In some embodiments,the improved liver function is an improvement in one or more liverfunction parameters (e.g., one, two, three, four, or more parameters)selected from the group consisting of serum albumin, bilirubin, alanineaminotransferase (ALT), aspartate aminotransferase (AST), andprothrombin activity. In some embodiments, treatment results in animprovement of at least 10%, at least 20%, at least 30%, at least 40%,at least 50% or more in one or more liver function parameters selectedfrom the group consisting of serum albumin, bilirubin, ALT, AST, andprothrombin activity. In some embodiments, treatment results in animprovement in one or more liver function parameters selected from thegroup consisting of serum albumin, bilirubin, ALT, AST, and prothrombinactivity to the level of a healthy control subject that is not infectedwith HDV or HBV. In some embodiments, treatment withlonafarnib-ritonavir co-therapy results in improved liver biopsy (e.g.,as assessed by histological staining, immunohistochemical staining,and/or fibrosis grading).

In some embodiments, treatment with lonafarnib-ritonavir co-therapydelays the need for a liver transplant in the patient. In someembodiments, treatment delays the need for a liver transplant for atleast 3 months, at least 6 months, at least 9 months, or at least 12months. In some embodiments, treatment delays the need for a livertransplant indefinitely.

Induction of an ALT Flare and Subsequent Suppression of HDV

In one aspect, methods for inducing an ALT flare in a patient infectedwith HDV are provided. As discussed herein, in at least some patientswith chronic HDV who are treated with lonafarnib therapy (e.g.,lonafarnib monotherapy or co-therapy with lonafarnib and ritonavir), anALT flare is induced that is followed by a significant reduction in HDVRNA titer (see, e.g., FIGS. 26-30 ). In at least some patients withinabout 12-24 weeks after the occurrence of an ALT flare, the patienttests negative for HDV RNA. In some patients, a subsequent rise in HDVRNA levels is observed following a period of HDV RNA negativity; withoutintending to be bound by a particular theory, it is believed that lowlevels of virus may persist in a “viral reservoir” in a patient whotests negative for HDV RNA using certain assays. In some situations thepersistent virus may expand (see, e.g., FIG. 26 ) and, if not eliminatedby the patient's immune response, may require further antiviraltreatment. This further antiviral treatment is typically treatment withlonafarnib, optionally as co-therapy with ritonavir and/or interferon.In general, the further treatment comprises administering lonafarnib,optionally as co-therapy with ritonavir and/or interferon, at a lowerdose and/or for a shorter duration of time than the initial pre-flaretreatment regimen.

For illustration and not limitation, Table 3 shows illustrativetreatment protocols.

TABLE 3 (A) (B) (C) (D) Duration (D) Duration (D) Duration (D) Duration(D) Stage Dose (O) Dose (O) Dose (O) Dose (O) First Course of D: 2-12weeks D: 2-12 weeks D: 2-4 weeks D: 24 weeks Treatment O: 50 mg BID O:50 mg BID O: 100 mg BID O: 50 mg BID e.g., 2-12 weeks, LNF optionallyLNF optionally LNF optionally LNF optionally usually 2-6 weeks with50-100 mg with 50-100 mg with 50-100 mg with 50-100 BID RTN BID RTN BIDRTN mg BID RTN Optional Second D: 2-4 weeks* D: 2-12 weeks D: 2-4 weeksNone course of O: 25 mg BID LNF O: 50 mgQD LNF O: 50 mg BID LNFtreatment optionally with optionally with optionally with e.g., 2-12weeks, 50-100 mg BID 50-100 mg BID 50-100 mg BID usually 2-6 weeks RTNRTN RTN Optional Third D: 12 weeks** D: 24 weeks D: 24 weeks None courseof O: 25 mg BID LNF O: 25 mg BID LNF O: 50 mg BID LNF treatmentoptionally with with 50-100 mg e.g., 12- 60 50-100 mg BID RTN weeks BIDRTN *Beginning after the first course of treatment. **Typicallybeginning after elevated HDV RNA levels (e.g., >3 log copies/mL) aredetected in patients in which an ALT flare was induced and HDV RNAlevels were reduced to clinically irrelevant levels, but may also begiven prophylactically 2-6 months following initiation of first courseof treatment.

As noted above, in addition to or as an alternative to monitoring an ALTflare, HBV DNA levels can be used to assess the efficacy of the initialtreatment. As one example, a patient with chronic HDV and a fibrosisscore of F3 is administered a first course of treatment of 50 mg BIDlonafarnib in combination with 100 mg BID ritonavir for 8 weeks (weeks1-8). The patient is then administered a second course of treatment of50 mg QD lonafarnib in combination with 100 mg BID ritonavir for 4 weeks(weeks 9-12). At week 12, the patient's HBV DNA levels is measured. Inone approach, if the patient has an HBV DNA increase >3 log, anti-HBVtreatment (e.g., using ETV or TNF) is initiated for 36 weeks (weeks13-48).

If the patient does not show evidence of immunologic reactivation (e.g.,has an HBV DNA increase <3 log) the patient receives a course oftreatment of anti-HBV treatment (e.g., ETV (or TNF)) in combination with50 mg BID lonafarnib and 100 mg BID ritonavir for 36 weeks (weeks13-48).

Reduction of Hepatitis B Virus (HBV) Viral Load

In one aspect, the invention relates to the treatment of a patient witha chronic hepatitis B virus (HBV) infection, in which the course oflonafarnib treatment or lonafarnib-ritonavir treatment (as describedherein) results in a reduction of the patient's HBV viral load comparedto the baseline level at the initiation of treatment and/or compared toa similarly infected patient not receiving treatment effective to reducethe patient's HDV viral load. See Example 15, below. In someembodiments, the methods for reducing HBV viral load in a patientinfected with HBV and HDV comprise administering lonafarnib therapy asdescribed herein and detecting a reduction of at least 1 log in HBVviral load. In some embodiments, treatment results in an at least 2 logreduction of HBV viral load. In some embodiments, the patient is notbeing treated with antiviral nucleotide or nucleoside analogs.

Without intending to be bound by any theory, it is believed that atleast some, if not most, patients will experience a decline in HBV viralload upon receipt of therapy in accordance with the invention, and thatsome patients, while unable to clear virus on therapy, will maintain thevirus at lower levels, relative to not receiving any treatment, and willexperience health benefits as a result.

IV. Pharmaceutical Compositions and Unit Dose Forms

In another aspect, the present invention provides unit dose forms andpharmaceutical compositions for providing lonafarnib and ritonavirco-therapy. In some embodiments, the lonafarnib in the unit dose form orpharmaceutical composition is amorphous lonafarnib. In otherembodiments, the lonafarnib is crystalline. In some embodiments, theritonavir in the unit dose form or pharmaceutical composition amorphousritonavir. In other embodiments, the ritonavir is crystalline. In someembodiments, lonafarnib and ritonavir co-administration is combined withprophylactic administration of one, two or three GI stabilizing agents,as discussed in Section VI below. In some embodiments, lonafarnib andritonavir co-administration is combined with interferon co-therapy, asdiscussed in Section V below.

Generally, for convenience, lonafarnib and ritonavir are formulated fororal administration and administered orally. However, in someembodiments, other routes may be preferred, so the present inventionprovides methods and compositions for the administration of lonafarniband/or ritonavir to a human for the treatment of HDV infection using oneor more other routes, such as administration of intravenous (IV) orsubcutaneous (SQ) formulations. As another example, the methods of theinvention can be practiced using patch technology, particularly patchtechnology that employ micro-needles, to administer the drugsubcutaneously. Non-oral administration may avoid or at least ameliorateGI and other side effects. Other routes suitable for drug delivery,including systemic and localized routes of administration, may be used.

In many embodiments, however, lonafarnib and/or ritonavir areadministered orally in solid dosage forms (e.g., capsules, caplets,tablets, and the like). In certain embodiments, lonafarnib and/orritonavir are administered orally as soft gel capsules comprisingliquid). In some embodiments, lonafarnib and/or ritonavir areadministered as a liquid dosage form (oral suspensions, syrups, orelixirs). Liquid dosage forms for oral administration may be providedwherein each dosage unit, for example, teaspoonful, tablespoonful,milliliter, and the like contains a predetermined amount of thecomposition containing lonafarnib and/or ritonavir. In some embodiments,lonafarnib and ritonavir are administered as a combination of twodifferent dosage forms (e.g., lonafarnib tablet and ritonavir solution).

Lonafarnib and ritonavir may be co-administered separately (as separateunit dosage forms) or may be combined in an oral unit dosage form thatcomprises both lonafarnib and ritonavir in the practice of the methodsdescribed herein. When administered as separate unit forms, typicallythe lonafarnib and ritonavir doses are administered (e.g.,self-administered) at about the same time, e.g., simultaneously orwithin about 3 minutes of each other, or alternatively, within about 10,30 or 60 minutes of each other. In some embodiments ritonavir isadministered before lonafarnib is administered.

Lonafarnib has been manufactured as 50 mg and 75 mg capsules, but theinvention provides, and it is within the ability of those of skill inthe art in view of this disclosure to prepare dosage forms withdifferent amounts of the lonafarnib as well as the ritonavir activeingredient. In one embodiment, a pharmaceutical formulation of theinvention contains lonafarnib formulated for oral administration as aunit dose form that contains 25 mg, 50 mg, or 75 mg of lonafarnib,including forms from which 50 to 100 mg of ritonavir is also present. Ifa salt or a solvate is used, equivalent amounts are used will berequired as is readily understood by the skilled artisan.

Ritonavir is commercially available as 100-mg tablets, 100-mg softgelatin capsules and an 80-mg/mL oral solution, but it is within theability of those of skill in the art in view of this disclosure toprepare dosage forms with different amounts of the active ingredient. Invarious embodiments, the unit dose form useful in the methods of theinvention contains 50 mg or 100 mg or some amount of ritonavir between50 mg and 100 mg. If a salt or a solvate is used, equivalent amounts areused as is readily understood by the skilled artisan.

Pharmaceutical formulations and unit dose forms suitable for oraladministration are particularly useful in the treatment of chronicconditions and therapies in which the patient self-administers the drug.However, as noted above, in some cases (including but not limited toacute infections and life-threatening conditions, particularly thoserequiring hospitalization) intravenous formulations are desirable, andthe present invention provides such formulations as well. The inventionprovides pharmaceutical formulations in which lonafarnib and/orritonavir can be formulated into preparations for injection inaccordance with the invention by dissolving, suspending or emulsifyingthe active pharmaceutical ingredients in an aqueous or nonaqueoussolvent, such as vegetable or other similar oils, synthetic aliphaticacid glycerides, esters of higher aliphatic acids or propylene glycol;and if desired, with conventional additives such as solubilizers,isotonic agents, suspending agents, emulsifying agents, stabilizers andpreservatives. Unit dosage forms for injection or intravenousadministration may comprise in a composition as a solution in sterilewater, normal saline or another pharmaceutically acceptable carrier.Appropriate amounts of the active pharmaceutical ingredient for unitdose forms of lonafarnib and/or ritonavir are provided herein.

Lonafarnib-Ritonavir Co-Formulations

In some embodiments of the invention, lonafarnib and ritonavir aredelivered to a patient in the same unit dosage form (i.e.,“co-formulated”). For example, a dosage form may contain lonafarnib andritonavir (along with excipients and auxiliary agents). Withoutlimitation, the lonafarnib and ritonavir may be provided as anadmixture, multiparticulate formulation (which may comprise smallparticles of lonafarnib in a matrix comprising ritonavir), bilayerformulation, a tablet-within-tablet formulation, and the like. Suchforms for co-administration are well known for other drugs (see, e.g.,US patent publications US 2009/0142393 and US 2008/0021078, andinternational patent publication WO 2009/042960, each of which isincorporated by reference herein), and such methodology can be used inaccordance with this disclosure to prepare suitable unit dosage forms.Liquid formulations containing both lonafarnib and ritonavir as providedherein may also be used for co-administration.

In some embodiments, lonafarnib and ritonavir are formulated with aco-polymer. In some embodiments, the co-polymer is selected from thegroup consisting of povidone (polyvinylpyrrolidone), hydroxypropylcellulose, hydroxypropyl methylcellulose (HPMC), hypromellose phthalate,polyvinylpyrrolidone-vinylacetate copolymer,hypromellose-acetate-succinate, and mixtures thereof. In someembodiments, the co-polymer is any one of povidone, hydroxypropylcellulose, HPMC, hypromellose phthalate,polyvinylpyrrolidone-vinylacetate copolymer, orhypromellose-acetate-succinate. In some embodiments, the co-polymer is amixture of two or more of povidone, hydroxypropyl cellulose, HPMC,hypromellose phthalate, polyvinylpyrrolidone-vinylacetate copolymer, andhypromellose-acetate-succinate. In some embodiments, the co-polymer ispovidone, hydroxypropyl cellulose, or hydroxypropyl methylcellulose(HPMC). In some embodiments, the co-polymer is apolyvinylpyrrolidone-vinylacetate copolymer. In some embodiments, theco-polymer is not povidone.

In some embodiments, the co-polymer is povidone (also known aspolyvinylpyrrolidone or PVP). In some embodiments, the co-polymer ispolyvinylpyrrolidone K12 (povidone K12), polyvinylpyrrolidone K17(povidone K17), polyvinylpyrrolidone K25 (povidone K25),polyvinylpyrrolidone K30 (povidone K30), or polyvinylpyrrolidone K90(povidone K90). In some embodiments, the polyvinylpyrrolidone ispolyvinylpyrrolidone K30. In some embodiments, the co-polymer ispolyvinylpyrrolidone-vinylacetate copolymer. In some embodiments, thepolyvinylpyrrolidone-vinylacetate copolymer is Kollidon® VA 64copovidone.

In some embodiments, a unit dose form or pharmaceutical compositioncomprising lonafarnib and ritonavir comprises lonafarnib in an amountfrom about 20 mg to about 100 mg, e.g., from about 25 mg to about 100mg, or from about 50 mg to about 100 mg, and comprises ritonavir in anamount from about 50 mg to about 100 mg. In some embodiments, lonafarnibis present in an amount of about 25 mg, about 50 mg, about 75 mg, orabout 100 mg, and ritonavir is present in an amount of about 50 mg,about 75 mg, or about 100 mg.

In some embodiments, the unit dose form or pharmaceutical composition isformulated for oral administration and comprises lonafarnib andritonavir in a ratio of about 1:2 (w/w) or about 1:4 (w/w). In someembodiments, a unit dose form or pharmaceutical composition compriseslonafarnib and ritonavir in a ratio of about 1:2 (w/w). In someembodiments, a unit dose form or pharmaceutical composition compriseslonafarnib and ritonavir in a ratio of about 1:4 (w/w). In someembodiments, a unit dose form or pharmaceutical composition compriseslonafarnib and ritonavir in a ratio of about 0.75:1 (w/w).

In some embodiments, a unit dose form or pharmaceutical compositioncomprises lonafarnib, ritonavir, and co-polymer in a ratio of about1:1:2 (w/w), 1:2:3 (w/w), or 1:1:5 (w/w).

In some embodiments, the unit dose form or pharmaceutical compositioncomprising lonafarnib, ritonavir, and a co-polymer is prepared accordingto a method described in International Application No.PCT/US2016/028651, incorporated by reference herein. In someembodiments, the unit dose form or pharmaceutical composition isprepared by a process comprising: providing a spray solution of thelonafarnib, ritonavir, and co-polymer in a solvent (e.g., an organicsolvent, e.g., dichloromethane, chloroform, isopropyl alcohol, methanol,ethanol, acetone, ethyl methyl ketone, methyl isobutyl ketone, DMSO,water, or a mixture thereof); optionally filtering the spray solution toremove insoluble matter; and substantially removing the solvent form thespray solution. In some embodiments, the solvent is removed bydistillation or complete evaporation of the solvent, spray drying,vacuum drying, tray drying, lyophilization or freeze drying, agitatedthin-film drying, or a combination thereof.

Defined Release Formulations

Lonafarnib and/or ritonavir dosage forms, including co-formulationscomprising lonafarnib and ritonavir, may be formulated for definedrelease profiles including immediate release and controlled release(e.g., delayed release or sustained release). For example, lonafarnibmay be formulated for delayed release and ritonavir may be formulatedfor immediate release (whether administered as separate or as acombination dosage form(s).

In some embodiments, the unit dosage form or pharmaceutical compositioncomprising lonafarnib, ritonavir, or lonafarnib and ritonavir as aco-formulation is formulated as a controlled release or delayed releaseformulation. Methods for making controlled or delayed releaseformulations are well known in the art. For illustration and notlimitation, in some cases, the lonafarnib, and optionally ritonavir, isformulated with a release-delaying agent. Lonafarnib in this formulationmay have zero or relatively low release of drug during a lag periodafter administration to the subject; and then achieves a rapid release(“burst”) of drug after the lag period ends. The lag period is typicallyin the range of about 0.25 to 3 hours, more often in the range of about0.5 to 2 hours. Many methods are known in the art for providingdelayed-burst release, such as by diffusion, swelling, osmotic burstingor erosion (e.g., based on the inherent dissolution of the agent andincorporated excipients); see U.S. Pat. Pub. No. 2011/0313009,incorporated by reference herein.

In some cases, for illustration and not limitation, the release-delayingagent is designed to allow release of lonafarnib and/or ritonavir uponexposure to defined conditions within the body. In one embodiment, therelease-delaying agent is an enteric release agent that allows therelease of the drug upon exposure to a characteristic aspect of thegastrointestinal tract. In an embodiment, the enteric release agent ispH-sensitive and is affected by changes in pH encountered within thegastrointestinal tract (pH sensitive release). The enteric materialtypically remains insoluble at gastric pH, then allows for release ofthe active ingredient in the higher pH environment of the downstreamgastrointestinal tract (e.g., often the duodenum, or sometimes thecolon). In another embodiment, the enteric material comprisesenzymatically degradable polymers that are degraded by bacterial enzymespresent in the lower gastrointestinal tract, particularly in the colon.Optionally, the unit dosage form is formulated with a pH-sensitiveenteric material designed to result in a release within about 0.25-2hours when at or above a specific pH. In various embodiments, thespecific pH can for example be about 4.5, 5, 5.5, 6, or 6.5. Inparticular embodiments, the pH-sensitive material allows release of atleast 80% of the drug within 1 hour when exposed to a pH of about 5.5 orhigher. In another embodiment, the pH-sensitive material allows releaseof at least 80% of the drug within 1 hour when exposed to a pH of about6 or higher.

Materials used for enteric release formulations, for example ascoatings, are well known in the art, for example, those described inU.S. Pat. Pub. No. 2011/0313009. Combinations of different entericmaterials may also be used. Multi-layer coatings using differentpolymers may also be applied. In some instances, the enteric materialscauses a delay of drug release in the range of about 0.25 to about 3hours, sometimes about 0.5 to about 4 hours.

Those of ordinary skill in the art can adjust the lag period beforedelayed-burst release from enteric coated multiparticulates by varyingthe enteric layer coating weight and composition. For example, wheretime in the stomach is <4 hours and some amount of protection (1-3hours) is desired after the dosage form leaves the stomach, then anappropriate level of coating that provides up to 4 hours of protectionbetween administration and drug release. can be prepared. To identifythe correct coating weight, samples of multiparticulates would be pulledfrom the fluid bed coater over a range of coating weights and tested viain vitro dissolution to determine the appropriate coating level. Basedon these results, the correct coating weight would be selected. Anexample of an enteric coated multiparticulate can be found in U.S. Pat.No. 6,627,223.

Lonafarnib and/or ritonavir may be mixed with (e.g., blended, intermixedor in continuous phase with) and/or contained within (e.g., encapsulatedwithin or coated with) one or more release-delaying agents. For example,the delayed-burst release formulation can be in the form of one or morecapsules containing lonafarnib and/or ritonavir. In other instances,lonafarnib and/or ritonavir can be in multiparticulate form such asgranules, microparticles (beads) or nanoparticles, coated with releasedelaying agents.

As described below in Section VI, in one approach it is contemplatedthat patients receiving lonafarnib will receive prophylacticadministration of one or a combination of GI modifying agent(s). In oneapproach, one or more GI modifying agents is provided as aco-formulation with lonafarnib and/or ritonavir. For example, withoutlimitation lonafarnib, ritonavir and a GI modifying agent may beformulated as a trilayer tablet. In another approach, one or more GImodifying agents provided in a common pharmaceutical package(“co-packaged”), as described below in Section VII. In one approach theone or more GI modifying agents are provided as an immediate releaseformulation and lonafarnib (and optionally ritonavir) is provided as acontrolled release formulation. The agents formulated with differentrelease may be co-packaged and/or co-formulated in a variety ofcombinations, provided that at least one GI modifying agent isformulated for rapid release and lonafarnib is formulated for controlled(e.g., delayed) release. In a preferred embodiment, the formulationsallow the patient to self-administer lonafarnib and at least one GImodifying agent at substantially the same time (e.g., simultaneously orwithin about 5 minutes of each other) using formulations that allow theGI modifying agent(s) to take effect prior to release of lonafarnib.Using this approach the patient may have the benefits of pre-release ofthe GI modifying agent without increasing the number of times per daythe patient must self-administer a therapeutic agent.

V. Interferon Co-Therapy

In some embodiments, lonafarnib is used in combination with interferonto treat HDV infection (i.e., HBV and HDV co-infection) or to reduce HDVviral load. In some embodiments, lonafarnib-ritonavir co-therapy is usedin combination with interferon to treat HDV infection or reduce HDVviral load.

Human interferons are classified into three major types based on thetype of receptor through which they signal. In various embodiments, aninterferon of any of Types I-Ill is used in combination with lonafarnibto treat HDV infection. All type I IFNs bind to a specific cell surfacereceptor complex known as the IFN-alpha receptor (IFNAR) that consistsof IFNAR1 and IFNAR2 chains. The type I interferons present in humansare IFN-alpha, IFN-beta, IFN-epsilon, and IFN-omega. Type II IFNs bindto IFN-gamma receptor (IFNGR) that consists of IFNGR1 and IFNGR2 chains.The type II interferon in humans is IFN-gamma. The recently classifiedtype III interferon group consists of three IFN-lambda molecules calledIFN-lambda1, IFN-lambda2 and IFN-lambda3 (also called IL29, IL28A, andIL28B, respectively). These IFNs signal through a receptor complexconsisting of IL10R2 (also called CRF2-4) and IFNLR1 (also calledCRF2-12). Suitable interferons for use in the treatment methodsdescribed herein are described below.

In one embodiment, lonafarnib is administered in combination with otheragents, (such as interferon alpha or interferon lambda and optionallyritonavir) at lonafarnib doses of 100 mg QD or less. In one embodiment,the invention provides a method for treating HDV infection byadministering at least 50 mg/day of lonafarnib (e.g., 25 mg BID, 50 mgBID, 75 mg BID, 100 mg BID, 50 mg QD, 75 mg QD, or 100 mg QD lonafarnib)in combination with ritonavir and/or an interferon. In one embodiment,the invention provides a method for treating HDV infection byadministration of at least 100 mg lonafarnib QD or BID in combinationwith an interferon and/or ritonavir.

In one approach, the patient receiving lonafarnib (either alone or incombination with a booster such as ritonavir) is also treated withinterferon (e.g., interferon alpha or interferon lambda). In someembodiments, both lonafarnib and the interferon (e.g., interferon alphaor interferon lambda) are administered to the patient, and thelonafarnib dose is at least about 25 mg BID, at least about 50 mg BID orQD, at least about 75 mg BID or QD, or about 100 mg BID or QD. In someembodiments, the administration of lonafarnib and the interferon (e.g.,interferon alpha or interferon lambda) is concurrent. In someembodiments, the administration of lonafarnib and the interferon (e.g.,interferon alpha or interferon lambda) is sequential. In someembodiments, the interferon is interferon alpha. In some embodiments,the interferon alpha is pegylated interferon alpha (e.g., pegylatedinterferon alpha-2a, also referred to herein as “Pegasys”). In someembodiments, the interferon is interferon lambda. In some embodiments,the interferon lambda is pegylated interferon lambda (e.g., peylatedinterferon lambda-1a). Thus, it is contemplated that HDV-infectedpatients receiving lonafarnib-ritonavir co-therapy may also be treatedwith an interferon.

Administration of lonafarnib in combination with other agents, such asinterferon (e.g., interferon alpha or interferon lambda) and ritonavir(Norvir) provides efficacious therapy at lower doses and/or reduceddosing frequency. Thus, in some cases, the patient is administered withlonafarnib, ritonavir and interferon (e.g., interferon alpha orinterferon lambda). In some embodiments, the interferon is administeredweekly at a dose of 120 micrograms (mcg) per week or 180 mcg per week.

In some embodiments, interferon alpha (e.g., Pegasys®, Genentech) isadministered weekly. In some embodiments, the interferon alpha isadministered at a dose of 120 mcg QW or 180 mcg QW. In some embodiments,pegylated interferon (Pegasys®) is administered at a dose of 180micrograms per week.

In some embodiments, interferon lambda (e.g., pegylated lambda, e.g.,pegylated lambda-1a) is administered weekly. In some embodiments, theinterferon lambda is administered at a dose of 120 mcg QW or 180 mcg QW.In some embodiments, the interferon lambda is administered at a dose of120 micrograms per week.

In these embodiments, dosing of lonafarnib (e.g., alone or incombination with ritonavir) and the interferon is continued for at least30 days, usually at least about 60 or even 90 days or longer, including6 months to a year or longer. In an approach administration will becontinuous for about 30 days, more typically 30 or 60 days, and often aslong 6 months, 9 months, and 12 months. In some embodiments, dosing willbe discontinued after virus levels have decreased to undetectable levelsfor a period of time (such as 1 to 3 months or longer).

Interferons

In one aspect, the present invention provides combination therapies inwhich an interferon-alpha or interferon-lambda are used in combinationwith lonafarnib. The term “interferon-alpha” or “IFN-α” and“interferon-lambda” or “IFN-λ” as used herein refers to a family ofrelated polypeptides that inhibit viral replication and cellularproliferation and modulate immune response. Suitable interferons forpurposes of the invention include, but are not limited to pegylatedIFN-α-2a, pegylated IFN-α-2b, consensus IFN, IFN-λ (e.g., IFN-λ1 such asIFN-λ1a), or pegylated IFN-λ (e.g., pegylated IFN-λ1 such as pegylatedIFN-λ1a).

Interferon Alpha

The term “IFN-α” includes naturally occurring IFN-α; synthetic IFN-α;derivatized IFN-α (e.g., PEGylated IFN-α, glycosylated IFN-α, and thelike); and analogs of naturally occurring or synthetic IFN-α. The term“IFN-α” also encompasses consensus IFN-α. Thus, essentially any IFN-α orIFN-λ that has antiviral properties, as described for naturallyoccurring IFN-α, can be used in the combination therapies of theinvention.

The term “IFN-α” encompasses derivatives of IFN-α that are derivatized(e.g., are chemically modified relative to the naturally occurringpeptide) to alter certain properties such as serum half-life. As such,the term “IFN-α” includes IFN-α derivatized with polyethylene glycol(“PEGylated IFN-α”), and the like. PEGylated IFN-α, and methods formaking same, is discussed in, e.g., U.S. Pat. Nos. 5,382,657; 5,951,974;and 5,981,709. PEGylated IFN-α encompasses conjugates of PEG and any ofthe above-described IFN-α molecules, including, but not limited to, PEGconjugated to interferon alpha-2a (Roferon, Hoffman La-Roche, Nutley,N.J.), interferon alpha-2b (Intron, Schering-Plough, Madison, N.J.),interferon alpha-2c (Berofor Alpha, Boehringer Ingelheim, Ingelheim,Germany); and consensus interferon as defined by determination of aconsensus sequence of naturally occurring interferon alphas (Infergen®,InterMune, Inc., Brisbane, Calif.).

Thus, in some embodiments of the combination therapies of the invention,the IFN-α has been modified with one or more polyethylene glycolmoieties, i.e., pegylated. Two forms of pegylated-interferon,peginterferon alfa-2a (40 kD) (Pegasys®, Genentech) and peginterferonalfa-2b (12 kD) (PegIntron®, Merck), are commercially available, whichdiffer in terms of their pharmacokinetic, viral kinetic, tolerabilityprofiles, and hence, dosing.

Peginterferon alfa-2a (Pegasys®) consists of interferon alfa-2a (^(˜)20kD) covalently linked to a 40 kD branched polyethylene glycol (PEG). ThePEG moiety is linked at a single site to the interferon alfa moiety viaa stable amide bond to lysine. Peginterferon alfa-2a has an approximatemolecular weight of 60,000 daltons. The biologic activity ofpeginterferon-alfa-2a derives from its interferon alfa-2a moiety whichimpacts both adaptive and innate immune responses against certainviruses. This alpha interferon binds to and activates human type 1interferon receptors on hepatocytes which activates multipleintracellular signal transduction pathways, culminating in theexpression of interferon-stimulated genes that produce an array ofantiviral effects, such as blocking viral protein synthesis and inducingviral RNA mutagenesis. Compared with the native interferon alfa-2a, thepeginterferon alfa-2a has sustained absorption, delayed clear.Peginterferon alfa-2a is used as a fixed weekly dose. Peginterferonalfa-2a has a relatively constant absorption after injection and isdistributed mostly in the blood and organs.

Peginterferon alfa-2b (PegIntron®) consists of interferon alfa-2bcovalently linked to a 12 kD linear polyethylene glycol (PEG). Theaverage molecular weight of the molecule is approximately 31,300daltons. Peginterferon alfa-2b is predominantly composed ofmonopegylated species (one PEG molecule is attached to one interferonmolecule), with only a small amount of dipegylated species. Fourteendifferent PEG attachment sites on the interferon molecule have beenidentified. The biologic activity of peginterferon alfa-2b derives fromits interferon alfa-2b moiety, which impacts both adaptive and innateimmune responses against certain viruses. This alpha interferon binds toand activates human type 1 interferon receptors on hepatocytes whichactivates multiple intracellular signal transduction pathways,culminating in the expression of interferon-stimulated genes thatproduce an array of antiviral effects, such as blocking viral proteinsynthesis and inducing viral RNA mutagenesis. Compared with the nativeinterferon alfa-2b, the peginterferon alfa-2b has sustained absorption,delayed clearance, and a prolonged half-life. Peginterferon alfa-2b isused as a weekly dose based on the weight of the patient. Peginterferonalfa-2b has a rapid absorption and a wider distribution in the body.

The PEG molecule of a pegylated IFN-α polypeptide is conjugated to oneor more amino acid side chains of the IFN-α polypeptide. In anembodiment, the pegylated IFN-α contains a PEG moiety on only one aminoacid. In another embodiment, the pegylated IFN-α contains a PEG moietyon two or more amino acids, e.g., the IFN-α contains a PEG moietyattached to two, three, four, five, six, seven, eight, nine, ten,eleven, twelve, thirteen, or fourteen different amino acid residues.IFN-α may be coupled directly to PEG (i.e., without a linking group)through an amino group, a sulfhydryl group, a hydroxyl group, or acarboxyl group.

The term “IFN-α” also encompasses consensus IFN-α. Consensus IFN-α (alsoreferred to as “CIFN” and “IFN-con” and “consensus interferon”)encompasses, but is not limited to, the amino acid sequences designatedIFN-con1, IFN-con2 and IFN-con3 which are disclosed in U.S. Pat. Nos.4,695,623 and 4,897,471; and consensus interferon as defined bydetermination of a consensus sequence of naturally occurring interferonalphas (e.g., Infergen®, Three Rivers Pharmaceuticals, Warrendale, Pa.).IFN-con1 is the consensus interferon agent in the Infergen® alfacon-1product. The Infergen® consensus interferon product is referred toherein by its brand name (Infergen®) or by its generic name (interferonalfacon-1). DNA sequences encoding IFN-con may be synthesized asdescribed in the aforementioned patents or other standard methods. In anembodiment, at least one additional therapeutic agent is CIFN.

In various embodiments of the combination therapies of the invention,fusion polypeptides comprising an IFN-α and a heterologous polypeptideare used. Suitable IFN-α fusion polypeptides include, but are notlimited to, Albuferon-Alpha™ (a fusion product of human albumin andIFN-α; Human Genome Sciences; see, e.g., Osborn et al., 2002, J.Pharmacol. Exp. Therap. 303:540-548). Also suitable for use in thepresent methods are gene-shuffled forms of IFN-α. See, e.g., Masci etal., 2003, Curr. Oncol. Rep. 5:108-113. Other suitable interferonsinclude Multiferon (Viragen), Medusa Interferon (Flame) Technology),Locteron (Octopus), and Omega Interferon (Intarcia/BoehringerIngelheim).

In one embodiment of these combination therapies, pegylated interferonalfa-2a (Pegasys) is administered weekly in dosages of 180 microgram(mcg) or 120 mg or 135 mcg (used for patients that react negatively tothe higher dose) subcutaneously (SQ). In another embodiment of thesecombination therapies, pegylated interferon alfa-2b (PegIntron) isadministered weekly in dosages of 1.5 mcg/kg/wk SQ. In other embodimentsof these methods, alfa-interferons are used as follows: consensusinterferon (Infergen) administered at 9 mcg to 15 mcg SQ daily or thriceweekly; interferon-alfa 2a recombinant administered at 3 MIU to 9 MIU SQadministered thrice weekly; interferon-alfa 2b (Intron A) recombinantadministered 3 MIU to 25 MIU SQ administered thrice weekly; andpegylated interferon lambda (IL-28) administered at 80 mcg to 240 mcg SQweekly.

In some embodiments, the interferon is pegylated IFN-alfa 2a orpegylated IFN-alfa 2b. Suitable doses of lonafarnib/pegylated IFN-alfa2a include, but are not limited to, 100 mg BID/180 mcg OW; 75 mg BID/180mcg OW; 50 mg BID/180 mcg OW; or 25 mg BID/180 mcg QW. Suitable doses oflonafarnib/pegylated IFN-alfa 2b include, but are not limited to, 100 mgBID/1.5 mcg/kg patient weight OW; 75 mg BID/1.5 mcg/kg patient weightOW; 50 mg BID/1.5 mcg/kg patient weight OW; or 25 mg BID/1.5 mcg/kgpatient weight QW.

Interferon Lambda

The term “IFN-λ” encompasses IFN-lambda-1 (which includesIFN-lambda-1a), IFN-lambda-2, and IFN-lambda-3. These proteins are alsoknown as interleukin-29 (IL-29), IL-28A, and IL-28B, respectively.Collectively, these 3 cytokines comprise the type III subset of IFNs.They are distinct from both type I and type II IFNs for a number ofreasons, including the fact that they signal through a heterodimericreceptor complex that is different from the receptors used by type I ortype II IFNs. Although type I IFNs (IFN-alpha/beta) and type III IFNs(IFN-lambda) signal via distinct receptor complexes, they activate thesame intracellular signaling pathway and many of the same biologicalactivities, including antiviral activity, in a wide variety of targetcells. Interferon lambda may be administered at any therapeuticallyappropriate dose, including, without limitation, 80, 120 or 180 mcg QW.In some embodiments, the dose for an adult human is 120 micrograms onceper week.

In some embodiments, interferon lambda (e.g., interferon lambda-1 orinterferon lambda-1a) is administered in conjunction with lonafarnib,and optionally with ritonavir, for treating a HDV infection in apatient. In some embodiments, the interferon lambda is a pegylated formof interferon lambda (e.g., pegylated interferon lambda-1 or pegylatedinterferon lambda-1a). In some embodiments, the interferon lambda is aninterferon disclosed in U.S. Pat. No. 7,157,559 incorporated byreference herein. In some embodiments, interferon lambda is administeredat a dose of 120 micrograms per week. In some embodiments, interferonlambda is administered at a dose of 180 micrograms per week. In someembodiments, the interferon lambda is subcutaneously administered. Insome embodiments, interferon lambda therapy is administered inconjunction with lonafarnib, and optionally with ritonavir, for treatinga HDV infection in a patient for at least 1 month, 2 months, 3 months, 4months, 5 months, 6 months or longer. Example 15 describes a propheticexample of administering interferon lambda in combination withlonafarnib and, optionally, ritonavir.

In some embodiments, the interferon is pegylated IFN lambda-1a. Suitabledoses of lonafarnib/pegylated IFN lambda-1a include, but are not limitedto, 100 mg BID/180 mcg OW; 75 mg BID/180 mcg OW; 50 mg BID/180 mcg QW;25 mg BID/180 mcg OW; 100 mg BID/120 mcg QW; 75 mg BID/120 mcg OW; 50 mgBID/120 mcg OW; or 25 mg BID/120 mcg QW.

Triple Therapy

In some embodiments, interferon lambda as described herein isadministered in combination with lonafarnib and ritonavir for treating aHDV infection in a patient. In some embodiments, the lonafarnib dose is50 mg BID, the ritonavir dose is 100 mg BID, and the interferon lambdadose is 120 mcg QW. In some embodiments, the lonafarnib dose is 50 mgBID, the ritonavir dose is 100 mg BID, and the interferon lambda dose is180 mcg QW. In some embodiments, the lonafarnib dose is 25 mg BID, theritonavir dose is 100 mg BID, and the interferon lambda dose is 120 mcgQW. In some embodiments, the lonafarnib dose is 25 mg BID, the ritonavirdose is 100 mg BID, and the interferon lambda dose is 180 mcg QW. Insome embodiments, the lonafarnib dose is 75 mg BID, the ritonavir doseis 100 mg BID, and the interferon lambda dose is 120 mcg QW. In someembodiments, the lonafarnib dose is 75 mg BID, the ritonavir dose is 100mg BID, and the interferon lambda dose is 180 mcg QW. In someembodiments, the lonafarnib dose is 50 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 120 mcg QW. In someembodiments, the lonafarnib dose is 50 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 180 mcg QW. In someembodiments, the lonafarnib dose is 75 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 120 mcg QW. In someembodiments, the lonafarnib dose is 75 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 180 mcg QW. In someembodiments, the lonafarnib dose is 100 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 120 mcg QW. In someembodiments, the lonafarnib dose is 100 mg QD, the ritonavir dose is 100mg QD, and the interferon lambda dose is 180 mcg QW.

VI. Prophylaxis with Gastrointestinal Modifying Therapies

As described in Example 2 and Example 4, below, some HDV-infectedpatients receiving lonafarnib monotherapy and lonafarnib-ritonavirco-therapy experienced gastrointestinal (GI) side effects. GI sideeffects are not unexpected of compounds in the farnesyl transferaseclass. GI intolerance is also a known side-effect of ritonavir, eventhough ritonavir may be dosed at doses as high as 1200 mg/day when usedas a protease inhibitor. However, the severity and persistence of thesesymptoms in HDV patients receiving lonafarnib given the comparativelymodest doses of lonafarnib and ritonavir was unexpected. Agents fortreatment of gastrointestinal irritations include anti-emetics, antacids(H2-receptor antagonists and proton pump inhibitors) andanti-diarrheals. Exemplary agents (for illustration and not limitation)are listed in Table 4 below.

In accordance with the methods of the present invention, lonafarnib isused in combination with at least one, at least two, or at least threeof an anti-emetic, an antacid (H2-receptor antagonist or proton pumpinhibitor) and/or an anti-diarrheal to allow for continued compliance ofpatients while on lonafarnib therapy. In one embodiment, ananti-diarrheal agent is administered. In one embodiment, ananti-diarrheal agent and an antacid are administered. In one embodiment,an anti-diarrheal agent and an anti-emetic are administered. In oneembodiment, an anti-diarrheal agent, an antacid and an anti-emetic areadministered. In one embodiment, the anti-diarrheal agent is lomotil(atropine/diphenoxylate) and/or the antacid is famotidine and/or theantiemetic is ondansetron.

TABLE 4 Exemplary GI Modifying Agents Class Exemplary agents Antiemetics5-HT₃ antagonists (such as ondansetron (Zofran ®), tropisetron(Navoban ®), granisetron (Kytril ®), palonosetron (Aloxi ®), anddolasetron (Anzemet ®)) and NKI receptor antagonists (such asaprepritant (Emend ®), casopitant, and fosaprepitant (Emend ® IV)).Antacids H2-receptor antagonists (such as ranitidine (Zantac ®),famotidine (Pepcid ®), cimetidine (Tagamet ®) and nizatidine (Axid ®)and Proton pump inhibitors (such as omeprazole (Prilosec ®),omeprazole/sodium bicarbonate (Zegerid ®), esomeprazole magnesium(Nexium ®), esomeprazole strontium, lansoprazole (Prevacid ®),dexlansoprazole (Dexilant ®), rabeprazole, and pantoprazole sodium(Protonix ®)). Anti- atropine/diphenoxylate (Lomotil ®, Lonox ®),loperamide HCI (Imodium ®), diarrheals and bismuth subsalicylate(Kaopectate ®, Pepto-Bismol ®).

In one approach, GI modifying therapies are administered on an as-neededbasis (in response to symptoms). In one approach, GI modifying therapiesare administered prophylactically. As used herein in this context,“prophylactically” refers to administration to a patient in the absenceof, or before development of, symptoms. Typically prophylactic treatmententails administration according to a fixed schedule (e.g., daily)during the course of lonafarnib treatment.

In one approach, prophylactic treatment comprises administration ofondansetron (anti-emetic), lomotil (atropine/diphenoxylate)(anti-diarrheal) and famotidine (antacid). For example, ondansetron maybe administered 8 mg BID, lomotil (atropine/diphenoxylate) may beadministered 5 mg QID or 5 mg BID, and famotidine may be administered 20mg BID.

In one approach, the GI modifying agents are administered daily, priorto administration of lonafarnib. In one approach GI modifying agents areadministered 30 minutes to two hours before administration of lonafarnibtherapy.

In one approach, the GI modifying agents are administered daily at thesame time lonafarnib is administered, but lonafarnib (and optionallyritonavir) are administered as a delayed release formulation (e.g.comprising an enteric coating) so that the GI modifying agents begin totake effect prior to lonafarnib release.

Prophylactic administration of GI modifying agents is generallycontinued for the duration of lonafarnib therapy.

In one approach, prophylactic administration of GI modifying agentscommences on the first day of lonafarnib administration. In anotherapproach, administration of one or more of the GI modifying agentscommences prior to initiation of oral lonafarnib-ritonavir therapy. Forexample, in one embodiment the patient takes ondansetron the day beforethe start of lonafarnib treatment. In one approach, one or more GImodifying agents are administered daily beginning more than one daybefore initiation of oral lonafarnib-ritonavir treatment.

In a preferred embodiment, a GI modifying agent is administeredaccording to a BID or QD schedule.

H2-Receptor Antagonists

In one embodiment of the GI modifying therapies, the GI modifyingtherapy is an H2-receptor antagonist. In one embodiment of the GImodifying therapies, ranitidine (Zantac®) is administered at a dose of150 mg twice daily, up to 150 mg four times daily for the duration oflonafarnib therapy. In another embodiment of these GI modifyingtherapies, famotidine (Pepcid®) is administered at a dose of 40 mg oncedaily, up to 20 mg twice daily, up to 40 mg twice daily for the durationof lonafarnib therapy. In another embodiment of the GI modifyingtherapies, cimetidine (Tagamet®) is administered at dose of 400 mg oncedaily, up to 800 mg once daily, up to 1600 mg once daily, up to 800 mgtwice daily, up to 300 mg four times daily, up to 400 mg four timesdaily, up to 600 mg four times daily for the duration of lonafarnibtherapy. In another embodiment of the GI modifying therapies, nizatidine(Axid®) is administered at dose of 150 mg once daily, up to 300 mg oncedaily, up to 150 mg twice daily for the duration of lonafarnib therapy.

5-HT₃ Antagonists

In one embodiment of the GI modifying therapies, the therapy is a 5-HT₃receptor antagonist. In one embodiment of the GI modifying therapies,ondansetron (Zofran®) is administered 30 minutes to two hours before thestart of lonafarnib therapy at 8 mg once daily, up to 8 mg two timesdaily, up to 8 mg three times daily. In this embodiment, administrationis continued at least for the duration of lonafarnib treatment. Inanother embodiment of the GI modifying therapies, granisetron (oralKytril®) is administered at 2 mg given up to one hour before the startof lonafarnib therapy or 1 mg twice daily. In this embodiment,administration is continued at least for duration of lonafarnibtreatment.

NK-1 Receptor Antagonists

In one embodiment of the GI modifying therapies, the GI modifyingtherapy is an NK-1 receptor antagonist. In one embodiment of the GImodifying therapies, aprepritant (Emend®) is administered in combinationwith an 5-HT3 receptor antagonist and a corticosteroid as a three daytreatment consisting of a 125 mg dose on day one given one hour beforestart of lonafarnib therapy, followed by an 80 mg dose on days two andthree. In another embodiment of the GI modifying therapies,fosaprepitant (Emend® IV) is administered in combination with an 5-HT3receptor antagonist and a corticosteroid (dexamethasone) as a single daytreatment consisting of one 150 mg dose of fosaprepitant given up to 30minutes before start of lonafarnib therapy followed by a single 12 mgdose of dexamethasone and a single dose of a 5-HT3 receptor antagonistsuch as odansetron, up to a single 150 mg dose of fosaprepitant given upto 30 minutes before start of lonafarnib therapy followed by a single 8mg dose of dexamethasone and a single dose of a 5-HT3 receptorantagonist such as ondansetron on day one, and a single 8 mg dose ofdexamethasone on days 2 through 4.

Proton Pump Inhibitors

In one embodiment of the GI modifying therapies, the GI modifyingtherapy is a proton pump inhibitor (PPI). In one embodiment of the GImodifying therapies, omeprazole (Prilosec®) is administered incombination with an antacid up to four days before the start oflonafarnib therapy at a dose of 20 mg once daily, up to 40 mg once dailyfor the duration of lonafarnib therapy. In another embodiment of the GImodifying therapies, omeprazole/sodium bicarbonate (Zegerid®) isadministered at least one hour before a meal and before the start oflonafarnib therapy at a dose of 20 mg once daily, up to 40 mg once dailyfor the duration of lonafarnib therapy. In another embodiment of the GImodifying therapies, esomeprazole magnesium (Nexium®) is administered atleast one hour before lonafarnib treatment at dose of 20 mg once daily,up to 40 mg once daily, up to 40 mg twice daily for the duration oflonafarnib therapy. In another embodiment of the GI modifying therapies,esomeprazole strontium is administered at least one hour beforelonafarnib treatment at dose of 24.65 mg once daily, up to 49.3 mg oncedaily, up to 49.3 mg twice daily, for the duration of lonafarnibtherapy. In another embodiment of the GI modifying therapies,lansoprazole (Prevacid®) is administered up to two hours beforelonafarnib therapy at a dose of 15 mg once daily of lansoprazole, up to30 mg once daily, up to 60 mg once daily, up to 30 mg two times dailyfor a duration up to 14 days, up to 30 mg three times daily for theduration of lonafarnib therapy. In another embodiment of the GImodifying therapies, dexlansoprazole (Dexilant®) is administered up totwo hours before lonafarnib therapy at a dose of 30 mg once daily ofdexlansoprazole, up to 60 mg once daily for the duration of lonafarnibtherapy. In another embodiment of the GI modifying therapies,pantoprazole sodium (Protonix®) is administered up to seven days beforelonafarnib therapy at a dose of 40 mg once daily, up to 40 mg twicedaily for the duration of lonafarnib therapy.

In some embodiments of the invention, the GI modifying therapy includesadministration of a proton pump inhibitor (PPI) selected due to itsinhibitory effect on CYP3A4. PPI-mediated inhibition can assist inmaintaining therapeutically effective lonafarnib serum levels. Suchinhibitory PPIs include, without limitation, omeprazole and rabeprazole.

Anti-Diarrheal Agents

In one embodiment of the GI modifying therapies, the therapy is ananti-diarrheal. In one embodiment of the GI modifying therapies,atropine/diphenoxylate (Lomotil®, Lonox®) is administered at a dose oftwo Lomotil tablets four times daily or 10 ml of Lomotil® liquid fourtimes daily (20 mg per day) until initial control has been achieved,after which the dosage may be reduced to as little as 5 mg (two tabletsor 10 ml of liquid) daily. In another embodiment of the GI modifyingtherapies, loperamide HCl (Imodium®) is administered at a dose of 4 mg(two capsules) followed by 2 mg (one capsule) after each unformed stool,up to 16 mg (eight capsules). In another embodiment of the GI modifyingtherapies, bismuth subsalicylate (Kaopectate®, Pepto-Bismol®) isadministered as 2 tablets or 30 mL every 30 minutes to one hour asneeded, up to eight doses in 24 hours.

VII. Kits and Packaging

Lonafarnib, and/or ritonavir, and/or an interferon and/or one or more GImodifying agents, for use in treating HDV and/or HBV patients, may bedelivered in a pharmaceutical package or kit to doctors and patients,e.g., HDV patients. Such packaging is intended to improve patientconvenience and compliance with the treatment plan. Typically thepackaging comprises paper (cardboard) or plastic. In some embodiments,the kit or pharmaceutical package further comprises instructions for use(e.g., for administering according to a method as described herein).

In some embodiments, a pharmaceutical package or kit comprises unit doseforms of lonafarnib comprising 25, 50, 75, or 100 mg lonafarnib per unitdose, or an amount between 25 mg and 100 mg lonafarnib per unit dose,and unit dose forms of ritonavir comprising 50 mg or 100 mg ritonavirper unit dose, or an amount between 50 mg and 100 mg ritonavir per unitdose. In some embodiments, the pharmaceutical package or kit furthercomprises, or comprises instead of ritonavir, unit dose forms ofinterferon. In some embodiments, the pharmaceutical package or kitcomprises unit dose forms of interferon comprising 120 mcg or 180 mcginterferon (e.g., pegylated interferon lambda-1a) per unit dose. In someembodiments, the pharmaceutical package or kit further comprises unitdose forms of one or more GI modifying agents (e.g., one or moreanti-emetics, antacids (H2-receptor antagonists and proton pumpinhibitors) or anti-diarrheal agents).

In one embodiment, the kit or pharmaceutical package compriseslonafarnib and ritonavir in defined, therapeutically effective doses incombination in a single unit dosage form or as separate unit doses. Thedose of each drug (e.g., in mg) and the form of the unit dose (e.g.,tablet, capsule, immediate release, delayed release, etc.) can be anydoses or forms as described herein (e.g. Section IV).

In one embodiment, the kit or pharmaceutical package includes dosessuitable for multiple days of administration, such as one week, onemonth, or three months. In a preferred approach, in multi-day packs thedoses (e.g., tablets) for each administration (e.g., once per day for QDadministration, twice per day for BID administration, etc.) areseparated from doses to be administered on different days or atdifferent times.

In another embodiment, the package comprises defined therapeuticallyeffective doses of lonafarnib, ritonavir, or a combination of lonafarniband ritonavir, and one or more GI modifying agents, which are combinedin a single package, but segregated from one another in separatecompartments within said package.

VIII. Other Antiviral Therapies

It is contemplated that HDV-infected patients receivinglonafarnib-ritonavir co-therapy may also be treated with other antiviralagents such nucleoside and nucleotide analogues, compounds used to treatHBV infections, and other agents.

Nucleoside and Nucleotide Analogs

Antiviral nucleoside or nucleotide analogues that may be used incombination with the lonafarnib-ritonavir cotherapy described hereininclude such as adefovir (Hepsera®), entecavir (Baraclude®), lamivudine(Epivir-HBV®, Heptovir®, Heptodin®), telbivudine (Tyzeka®), tenofovir(Viread®), and ribavirin (such as Rebetol® or Copegus®).

Compounds Used to Treat HBV

In various combination therapies of the invention, for treatment of HDV,lonafarnib is combined with an antiviral medication directed againstHBV. Anti-HBV medications that are currently approved, with theexception of interferons, inhibit reverse transcriptase and arenucleoside or nucleotide analogues. These medications, while effectiveagainst HBV, are not effective against HDV as they do not clear HBsAg,which HDV needs to replicate; however, when used in the combinationtherapies of the invention, improved patient outcomes can be achieved.Currently approved anti-HBV medications include: interferon alpha(Intron A®), pegylated interferon (Pegasys®), lamivudine (Epivir-HBV®,Zeffix®, or Heptodin®), adefovir dipivoxil (Hepsera®), entecavir(Baraclude®), telbivudine (Tyzeka®, Sebivo®), clevudine (Korea/Asia),tenofovir (Viread®). Truvada®, which is a combination of tenofovir andemtricitabine, is not yet approved but has been shown to be effective inreducing HBV viral titers in early clinical trials and is useful in thecombination therapies of the invention.

Other Therapeutic Compounds

Other therapeutic compounds that may be administered with beneficialeffect to an HDV-infected patient that is being treated in accordancewith the invention include a nucleoside or nucleotide analog; athiazolide; a protease inhibitor; a polymerase inhibitor; a helicaseinhibitor; a Class C CpG toll-like receptor 7 and/or 9 antagonist; anamphipathic helix disruptor or NS4B inhibitor; a statin or other HMG CoAreductase inhibitor; an immunomodulator; an anti-inflammatory; a secondprenylation inhibitor; a cyclophilin inhibitor; and an alpha-glucosidaseinhibitor.

Other Therapeutic Modules

Oral lonafarnib-ritonavir co-therapy may be one module in a course oftherapies for rapid and complete clearance of HDV infection. Thus, thetreatment regimens described herein may be preceded by or followed bycomplementary therapies.

As one example, some patients may benefit from an initial IV infusion oflonafarnib to achieve high blood levels of the drug rapidly, whichlevels may be sustained by continuous or periodic IV infusion(s) forsome period (one to a few days or perhaps a week) before a patient isplaced on the oral therapies more specifically described herein. Inthese embodiments, a patient may be infused with the drug to achieve thetherapeutic efficacy associated with serum levels achieved with 50 mgBID administration (and higher doses). The IV administration is doneunder the care of a physician other trained medical professional (forexample, in a hospital), with the prophylactic therapy and monitoring toavoid or ameliorate the AEs associated with oral dosing at those highdoses or to discontinue IV administration, if necessary. In otherembodiments, subcutaneous infusions to provide a depot form of the drugthat maintains therapeutically effective blood levels of the drug forsome days or weeks may be used to achieve the same therapeuticallyeffective results as those described herein for oral therapy.

IX. Use of Cobicistat as Boosting Agent

While ritonavir is the most widely used CYP3A4 inhibitor, the inventionalso provides lonafarnib combination treatments and therapies with otherCYP3A4 inhibitor inhibitors. In one alternative, the invention providesembodiments, described elsewhere herein as well, in which thepharmacokinetic boosting agent cobicistat is used in combination withlonafarnib in place of ritonavir.

Cobicistat (marketed under the tradename Tybost® by Gilead Sciences) isa potent inhibitor of CYP3A. As does ritonavir, it “boosts” blood levelsof other substrates of this enzyme but, unlike ritonavir, it has noanti-viral activity. In addition, while it has a pronounced effect onthe enzyme system (CYP3A) responsible for breaking down certain drugs,it does not affect other enzyme systems used by many other medicationswhich may contribute to numerous potentially harmful drug interactions.

In one aspect, the invention provides treatment of HDV patients usingthe methods and compositions described herein, except that a boostingagent other than ritonavir is used. In one embodiment the boosting agentcobicistat is used in the methods and compositions described herein.Cobicistat is useful in the combination therapies of the invention atits approved or any lower dose in combination with lonafarnib at anydose and dosing frequency described herein. In alternative embodimentscobicistat is administered at a lower (e.g., 75 mg) and/or more frequent(e.g., BID) dose than has been approved for use in the treatment of HIVinfection. In some embodiments, a lower dose of cobicistat is used(e.g., 50 mg QD or 50 mg BID).

Exemplary doses for lonafarnib-cobicistat co-therapy, for illustrationand not for limitation, are provided in Table 5 below. In someembodiments, lonafarnib is dosed at 100 mg QD or 100 mg BID andcobicistat (Tybost®) is administered at 150 mg once daily.

Each of dosing schedules A-G may be administered with prophylactic GImodifying agents (e.g., an anti-emetic agent, an anti-diarrheal agent,and an antacid), and/or with an interferon (e.g., interferon alpha orinterferon lambda). See Section V and Section VI above. In oneembodiment, lonafarnib-cobicistat co-therapy is administered incombination with an interferon.

TABLE 5 A B C D E F G Dose 100 mg BID 75 mg BID 50 mg BID 25 mg BID 100mg QD  50 mg QD  75 mg QD lonafarnib Dose 150 mg QD 150 mg QD 150 mg QD150 mg QD 150 mg QD 150 mg QD 150 mg QD cobicistat

X. EXAMPLES

The following examples are offered to illustrate, but not to limit, theclaimed invention.

Example 1. Treating HDV Patients with 100 mg Lonafarnib Administered BID

This example demonstrates lonafarnib's efficacy to reduce HDV RNA levelsin patients with chronic HDV. The eight Group 1 patients (all withchronic HDV) were treated as follows: 6 patients (patients 1, 2, 4, 5,6, and 8) with chronic delta hepatitis (HDV) were treated withlonafarnib and 2 patients (patients 3 and 7) were administered placebofor a duration of twenty-eight days. The 6 patients in the activetreatment group were dosed at 100 mg BID (orally administered) for 28days. The mean change in HDV RNA levels from baseline to nadir in thelonafarnib active treatment group was −0.74 log HDV RNA copies/mL and inthe placebo group was −0.24 log HDV RNA copies/mL.

Patients 4, 5, 6 and 8 were responsive to therapy, as defined by greaterthan or equal to a 0.5 log HDV RNA copies/mL decline in quantitativeserum HDV RNA levels from baseline to nadir during active treatment. SeeTable 6 (showing change in HDV RNA viral load for each patient, duringtreatment and post-treatment) and FIG. 1 (showing the time course of thelog HDV RNA copies/mL levels of patients 4, 5, and 6). The change inpatient 4's HDV RNA levels from baseline to the end of the treatment(EOT) was −1.34 log HDV RNA copies/mL. The change in patient 5's HDV RNAlevels from baseline to EOT was −0.82 log HDV RNA copies/mL. The changein patient 6's HDV RNA levels from baseline to EOT was −1.41 log HDV RNAcopies/mL.

TABLE 6 100 mg BID Lonafarnib Monotherapy Baseline vs EOT on Rx vs PostPatient Patient Patient Patient Patient Patient Patient Patient 1 2 4 56 8 3 7 Dose lonafarnib (mg BID) 100 100 100 100 100 100 Placebo PlaceboComposite Baseline 7.33 8.08 7.77 8.59 8.78 7.19 7.29 8.33 (logcopies/mL) Change log Baseline to EOT −0.20 −0.19 −1.34 −0.82 −1.41−0.46 −0.29 −0.14 Change log Baseline to post-FU −0.10 +0.27 −0.16 −0.43−1.63 +0.20 −0.10 −0.13HDV RNA Viral Load Correlates with Plasma Concentrations of Lonafarnib.

FIG. 2 illustrates the correlation between plasma levels of lonafarniband viral load. Patients with higher plasma levels of lonafarnibexperienced greater declines in HDV RNA titers during treatment. Plasmalevels ranged between 200 ng/mL and 1,100 ng/mL during treatment.

Post-Treatment Viral Rebound

Patients 4, 5, and 6 exhibited viral rebound or an increase in serum HDVRNA levels after lonafarnib therapy was discontinued on day 28. Patient4's HDV RNA level increased 1.7 log HDV RNA copies/mL afterdiscontinuation of lonafarnib. Patient 5's HDV RNA level increased 1.4log HDV RNA copies/mL after discontinuation of lonafarnib. Patient 6'sHDV RNA level increased after discontinuation of lonafarnib. Patients 4,5, and 6 exhibited subsequent decreases in HDV RNA levels, beginningapproximately 4-8 weeks after lonafarnib therapy was discontinued, whichis considered to be attributed to virus to virus dynamics between HDVRNA and HBV DNA.

Example 2. Treating HDV Patients with 200 mg and 300 mg LonafarnibAdministered BID

Six human subjects known to be infected with HDV, as documented bybaseline HDV RNA viral titers ranging from 5.8 log HDV RNA copies/mL to8.78 log HDV RNA copies/mL, were treated with lonafarnib at doses ofeither 200 mg BID or 300 mg BID for a period of 84 days.

Effect of 28 Days Treatment

At the end of 28 days of treatment, the mean change in viral load acrossthe six subjects from baseline to day 28 was −1.63 log copies/mL for the200 mg BID group and −2.00 log copies/mL for the 300 mg BID group. SeeTable 7 and FIG. 3 .

TABLE 7 300 mg BID 200 mg BID lonafarnib lonafarnib Patient PatientPatient Patient Patient Patient 1 2 3 4 5 6 HDV RNA viral 5.8 7.7 7.668.78 6.06 8.19 load baseline (log copies/mL) Δ log Baseline to −1.95−1.97 −2.07 −1.85 −1.06 −1.98 Day 28

The results at Day 28 demonstrated superior efficacy of the 200 mg BIDand 300 mg BID administration schedule over the 100 mg BIDadministration schedule. However, additional efficacy with fewer sideeffects was believed to be required for significant therapeutic benefit.

Effect of 56-84 Day Treatment

When 200 mg BID and 300 mg BID dosing was continued for 56 days (days29-56 may be referred to as Month 2) and 84 days (days 57-84 may bereferred to as Month 3), the change in viral loads across the sixpatients either plateaued or increased from viral load levels at 28days. This no change or rise in viral loads was attributed to poorgastrointestinal tolerance to lonafarnib and associated poor compliancewith protocol. These six patients did not receive GI modifying agentsprophylactically to mitigate gastrointestinal distress. It is likelythat compliance or drug absorption or both were suboptimal due to GIintolerance and attendant side effects.

Example 3. Combination Treatment of HDV Patients with 100 mg BIDLonafarnib and Interferon

Three human subjects known to be infected with HDV, as documented bybaseline HDV RNA viral titers ranging from 4.34 log HDV RNA copies/mL to5.15 log HDV RNA copies/mL and ALT values ranging from 155-174 IU/L,were treated with lonafarnib in doses of 100 mg BID in combination withPegasys® (peg interferon alfa-2a) 180 μg per week for a period of 56days (2 months).

At the end of 28 days, all three patients' HDV RNA viral titers haddecreased from baseline, ranging from −1.04 log HDV RNA copies/mL to−2.00 log HDV RNA copies/mL drop in HDV-RNA, with an average drop acrossthe three subjects of −1.8 log HDV RNA copies/mL. At the end of 56 days,all three patients' HDV RNA viral titers continued to decline with amean viral load decline of 3 log copies/mL at day 56. In addition, theALT values of all three patients decreased from baseline through day 56,continuing to decline after therapy was stopped, normalizing in two ofthree patients by post week 4 of treatment cessation. Upper limit ofnormal for ALT values is estimated to be 40 U/L.

The change in HDV RNA viral load and ALT values for each patient istabulated below in Table 8. See also FIG. 4 .

TABLE 8 Combination therapy of lonafarnib 100 mg BID and PEG IFN 180 mcgQW ALT (U/L)* Day 1 to Day 28 to Log HDV RNA copies/mL Day 56 to PostPatient Day 1 Day 2 Day 3 Day 7 Day 14 Day 28 Change Wk 4** 1 5.15 5.284.98 4.32 4.04 3.64 −1.51 161 → 73 → 66 → 28 2 5.04 5.15 5.04 4.43 4.344.00 −1.04 174 → 144 → 69 → 55 3 4.34 4.15 4.04 4.04 2.34 2.34 −2.00 155→ 80 → 56 → 40 *Upper limit of normal = 40 U/L **Post Wk 4 refers to theend of the first week following termination of treatment.

These viral load results demonstrate comparable efficacy to the 200 mgBID lonafarnib regimen and superior efficacy over the 100 mg BIDlonafarnib regimen and fewer grade 2 adverse events (AEs) compared to200 mg BID lonafarnib.

Example 4. Combination Treatment of HDV Patients with 100 mg BIDLonafarnib and 100 mg QD Ritonavir

Three human subjects known to be infected with HDV, as documented bybaseline HDV RNA viral titers ranging from 5.14 log HDV RNA copies/mL to6.83 log HDV RNA copies/mL and ALT values of 84-195 U/L, were treatedwith lonafarnib at doses of 100 mg BID in combination with ritonavir atdoses of 100 mg QD for a period of 8 weeks, substantially as otherwisedescribed in Example 1.

At the end week 4, all three patients' HDV RNA viral titers haddecreased from baseline, ranging from −1.71 log HDV RNA copies/mL to atleast −2.76 log HDV RNA copies/mL drop in HDV-RNA, with an average dropacross the three patients of −2.2 log HDV RNA copies/mL. At the end ofweek 8, all three patients' HDV RNA viral titers continued to decrease,with patient 2's viral titers being undetectable. See FIG. 5 . Theaverage viral load decline for the three patients at week 8 was −3.2 logHDV-RNA.

In addition, all three subjects' ALT values decreased from baseline,ranging from 35-50 U/L. Upper limit of normal for ALT values isestimated to be 40 U/L. See Table 9, which also shows the change in HDVRNA viral load for each patient.

TABLE 9 Combination therapy of 100 mg lonafarnib BID and 100 mgritonavir QD ALT (U/L)* Log HDV RNA copies/mL Baseline to PatientBaseline Wk 1 Wk 2 Wk 4 Wk 5 Wk 6 Wk 8 Change Wk 4 to Wk 8 1 6.34 4.964.40 4.63 4.48 4.18 3.97 −2.37  83 → 50 → 43 2 5.14 4.21 3.30 2.38 1.862.08 ND** >−5 206 → 58 → 32 3 6.83 5.82 5.38 4.68 4.62 4.23 3.99 −2.84 72 → 35 → 43 *Upper limit of normal = 40 U/L **Below detection limit.

These results demonstrate superior efficacy compared to 200 mg BID and300 mg BID lonafarnib monotherapy and over the combination treatment of100 mg BID lonafarnib and Pegasys® (peg interferon alfa-2a) 180 μg perweek. In addition, there were fewer grade 2 AEs observed as compared to200 mg BID lonafarnib. See Table 10.

TABLE 10 N = 3 N = 3 LNF 100 mg LNF 100 mg N = 3 N = 3 BID BID LNF 200mg LNF 300 mg RTN 100 mg PEG IFN BID BID QD 180 mcg QW Grade 1 2 3 4 1 23 4 1 2 3 4 1 2 3 4 Nausea ✓ ✓ ✓ ✓ Diarrhea ✓ ✓ ✓ ✓ Fatique ✓ ✓ ✓ ✓ WtLoss ✓ ✓ ✓ ✓ Anorexia ✓ ✓ ✓ ✓

Table 11 below shows the mean serum concentrations obtained withlonafarnib monotherapy (200 mg BID or 300 mg BID), lonafarnib-ritonavirco-therapy (100 mg BID lonafarnib in combination with 100 mg QDritonavir), and lonafarnib-interferon co-therapy (100 mg BID lonafarnibin combination with 180 mcg QW pegylated interferon) at specifictimepoints.

TABLE 11 Mean Serum Concentrations (ng/mL) N = 3 N = 3 N = 3 N = 3 LNF200 LNF 300 LNF 100 mg BID LNF 100 mg BID mg BID mg BID RTN 100 mg QDPeg IFN 180 mcg QW Day 7  2555 2994 2745  587 Day 14 2959 1548 2720  896Day 21 Day 28 2771 1984 2741  572 Day 35 2860 1325 Day 42 3633 Day 561656 2032 3767  643 Day 84  443  977

Example 5. Treatment of HDV Patients with Lonafarnib and Ritonavir

The example describes the anti-HDV effect of the combination therapy oflonafarnib and ritonavir. Eight patients with chronic HDV infection weretreated with four different dose combinations of lonafarnib andritonavir (orally administered) for 84 days under the regimenssummarized in Table 12.

Results

The changes in patients' HDV RNA levels from baseline as a result oflonafarnib and ritonavir combination therapy are summarized in Table 12below.

TABLE 12 Lonafarnib-Ritonavir Co-therapy Patient Patient Patient PatientPatient Patient Patient Patient 1 2 3 4 5 6 7 8 Group Group 1 Group 2Group 3 Group 4 Dose lonafarnib 100 mg BID 100 mg BID 100 mg QD 150 mgQD Dose ritonavir 100 mg QD  50 mg BID 100 mg QD 100 mg QD Change log VLBaseline to −2.32 −3.37 −2.37 −1.99 −2.05 −2.12 −1.45 −1.39 Nadir Changelog VL Baseline to −2.32 −2.45 −2.37 −1.94 na −2.01 −1.39 −1.39 Day 28Change log VL Baseline to −1.56 −2.23 −1.79 −1.20 −1.58 −1.61 −1.00−0.70 Day 56 Change log VL Baseline to −1.47 −0.61 1.09 −0.62 −2.05−2.00 −0.71 0.21 Day 84* LNF Serum Concentration 3101 4827 3474 4580 Nodata 1411 1198 2042 at Week 4 (ng/mL) LNF Serum Concentration 1678 14843070 2969 1502 1662 1475 3139 at Week 8 (ng/mL) LNF Serum Concentration1243 0 2377 423 1337 1807 1727 0 at Week 12 (ng/mL) *See TABLE 12 fordiscussion of dose reductions in weeks 7-12

Time courses showing changes in HDV RNA levels in patients 1-8 throughDay 28, Day 56 and Day 84 are shown in FIGS. 6A, 6B, and 6C,respectively (change relative to a normalized baseline). The mean changein log viral load was −1.89 after Day 28, −1.86 after Day 56 and −1.62after Day 84. Nadirs were reached between week 4 to 6, after which viralload (VL) plateaued or in some cases, elevated slightly. Group 4 mayhave reached a saturable absorption point, supporting potentially evengreater efficacy of a lower lonafarnib dose.

Groups 1 and 2 maintained the highest C_(min). These two groups receivedeither BID lonafarnib (Group 1) or BID ritonavir (Group 2). Theseresults support the conclusion that higher or more frequent ritonavirdoses are beneficial, e.g., BID administration. FIG. 10 illustrates thatQD dosing of ritonavir (as shown in the graph) provides lonafarnib (LNF)serum concentrations that are in the 2500-3500 ng/mL range. Increasingritonavir dosing to BID in patients may achieve higher lonafarnib serumconcentrations of >5000 ng/mL.

The correlation of increasing serum levels of lonafarnib with decreasinglevels of HDV RNA in hepatitis delta infected patients treated withlonafarnib-ritonavir co-therapy is exemplified in patient 2 (FIG. 7 )and patient 8 (FIG. 8 ). Patients with serum lonafarnib levels below2000 ng/mL, such as patient 8 for example, are likely to have lowerviral load declines (<1.5 log HDV-RNA) compared to patients withlonafarnib levels approaching or greater than 5,000 ng/mL (>2 logHDV-RNA).

Adverse Effects

Table 13 summarizes patients' adverse events during the first 6 weeks oftherapy, and shows that 75% of patients in the study (six of eightpatients) required at least one dose reduction in weeks 7-10. Dosereductions often resulted in a rise or plateau in HDV RNA levels.

TABLE 13 Lonafarnib Dose Reductions in Patients Experiencing SideEffects Adverse events of LOWR2 patients during Patient Lonafarnib DoseReduction the course of the six week treatment 1 Dose reduction at “week7” from Diarrhea and severe fatigue 100 mg BID to 100 mg QD 2 Dosereduction at “week 7” from Diarrhea. Fatigue and anorexia unbearable 100mg BID to 50 mg (am) + 100 mg (pm) 3 Dose reduction at “week 8” fromDiarrhea 2-3 times in a week (5-6 times per 100 mg BID to 150 QD day),anorexia, fatigue 4 Dose reduction at “week 8” from Severe anorexia, drymouth, diarrhea 2-3 100 mg BID to 150 mg QD days per week Further dosereduction at “week 10” from 150 mg QD to 50 mg QD 5 Dose reduction at“week 7” from Diarrhea 2 days per week, 3-4 bowel 100 mg QD to 50 mg QDmovements per day, anorexia and vomiting, fatigue 6 No dose reductionsnausea (moderate), diarrhea (rarely 7 No dose reductions Diarrheacontinued (7-8 times per day), anorexia (moderate) 8 Dose reduction a“week 10” from Diarrhea 20 times per day, mild 150 mg QD to 100 mg QDanorexia and nausea, severe fatigue

Lonafarnib dose was reduced in 6 of 8 patients (patients 1, 2, 3, 4, 5,8) due to side effects. Dose reductions correlated with viral loadplateau or increase. Lomotil and ondansetron were used by three of theeight patients (beginning at week 4). Of these three patients, two didnot require lonafarnib dose reduction.

Example 6. Treatment of HDV Patients with Low Doses ofLonafarnib-Ritonavir Cotherapy and Lonafarnib-Ritonavir-PegylatedInterferon Alpha Triple Therapy

FIG. 12 shows HDV levels in three patients with chronic HDV infection(Patients 13, 14 and 15) treated with lonafarnib (75 mg BID) incombination with ritonavir (100 mg BID) for 12 weeks. At week 12,ritonavir administration was discontinued and PEG-IFN-α was administered(180 mcg QW). At week 16, ritonavir (100 mg BID) administration wasreinitiated.

Results

Time courses showing changes in HDV RNA levels in patients 13, 14 and 15are shown in FIG. 12 (change relative to a normalized baseline). BetweenWeeks 12 and 16 (lonafarnib-interferon co-therapy) viral load was aboutconstant (patients 13 and 15) or increased (patient 14). From Week 16 toWeek 20, the patients received triple therapy resulting in a significantdecrease in viral load (patients 13 and 14).

Example 7. Triple Therapy with Low (50 mg BID) Dose Lonafarnib

Three patients with chronic HDV infection (patients 25, 26 and 27) weretreated with lonafarnib (50 mg BID), ritonavir (100 mg BID), andpegylated interferon alpha (180 mcg QW) for 4 weeks. See FIG. 13 . Asignificant reduction in viral load was seen at 2 weeks. At 4 weeks allpatients had significantly reduced viral load relative to baseline.These results support the conclusion that lower doses of lonafarnib canbe administered in combination with a boosting agent (e.g., ritonavir)and an interferon (e.g., interferon alpha or interferon lambda) thatenable patients to achieve significant therapeutic benefit.

Example 8. Triple Therapy with Low (50 mg BID) and Very Low (50 mg QD)Dose Lonafarnib

FIG. 14 shows the effect on viral load of triple therapy in 3 patientswith chronic HDV infection. Patients 2 and 3 received 50 mg BIDlonafarnib, 100 mg BID ritonavir, and 180 mcg QW pegylated interferonalpha for 8 weeks. Patient 1 received 50 mg BID lonafarnib, 100 mg BIDritonavir, and 180 mcg QW pegylated interferon alpha for almost 3 weeks,at which time the dose of lonafarnib was reduced to 50 mg QD (except for1 day during week 8 on which 50 mg BID was administered). The patientsreceived proton pump inhibitors (esomeprazole or rabeprazole on a QDbasis) and an anti-diarrheal (lomotil or loperamide BID or TID).

As shown in FIG. 14 , the mean decrease in log HDV viral load is greaterthan 2 (patient 3) or greater than 3 (patient 2) after 8 weeks at the 50mg BID dose, and was greater than 3 (patient 1) at the 50 mg QD dose.The therapy was well tolerated, with diarrhea the most prominent sideeffect, indicating that triple therapy is well suited for long termtherapy (6 months or greater).

Example 9: Exemplary Treatment Regimens

This prophetic example describes treating HDV infection byadministration of varying doses of lonafarnib and ritonavir as disclosedin Table 14 below. A patient infected with HDV self-administers thefollowing regimen daily for 90-180 days. During the course of thetreatment the patient's lonafarnib serum levels and HDV viral load aredetermined periodically. After 90 days of treatment the patient's viralload is reduced over baseline.

TABLE 14 Illustrative Embodiment 9 Illustrative Embodiment 10Illustrative Embodiment 11 lonafarnib 50 mg QD lonafarnib 50 mg BIDlonafarnib 75 mg QD ritonavir 100 mg QD ritonavir 50 mg BID ritonavir100 mg QD ondansetron 8 mg BID ondansetron 8 mg BID lomotil 5 mg BIDlomotil 5 mg BID famotidine 20 mg BID. famotidine 20 mg BID.Illustrative Embodiment 12 Illustrative Embodiment 13 IllustrativeEmbodiment 14 lonafarnib 75 mg BID lonafarnib 25 mg BID lonafarnib 50 mgBID ritonavir 50 mg BID ritonavir 100 mg BID ritonavir 100 mg BIDondansetron 8 mg BID ondansetron 8 mg BID lomotil 5 mg BID* lomotil 5 mgBID famotidine 20 mg BID famotidine 20 mg BID. omeprazole 20 mg BID*titrate to dose

Example 10. A Phase 2 Study to Evaluate the Safety, Tolerability, andPharmacodynamics of Pegylated Interferon Lambda-1a (PEG-IFN-λ)Monotherapy in Patients with Chronic Hepatitis D Virus Infection

This prophetic example describes a Phase 2 clinical study protocol forevaluating the safety, tolerability, and pharmacodynamics of pegylatedinterferon lambda monotherapy in patients with chronic HDV infection.The efficacy demonstrated by interferon lambda monotherapy in thisprotocol is indicative that interferon lambda therapy in combinationwith lonafarnib, and optionally in combination with an additionalboosting agent such as ritonavir, will be efficacious for the treatmentof HDV infection.

Two dose levels of PEG-IFN-λ, (120 μg per week or 180 μg per week areadministered by subcutaneous injection over a 48 week treatment periodand the safety and tolerability of treatment is evaluated based on HDVlevels, ALT levels, and Hepatitis B surface antigen (HBsAg) levels.

At least one patient from the cohort of patients who receive at least80% of the total study drug dose throughout the entire 48-week treatmentperiod and for whom HDV viral load data are available for the Day 1(baseline) and end-of-treatment (Week 48) study visits shows improvementin one or more endpoints as described in the protocol. In someembodiments, a patient receiving treatment with interferon lambdamonotherapy exhibits a reduction in HDV viral load at end-of-treatmentas compared to baseline. In some embodiments, a patient receivingtreatment with interferon lambda monotherapy exhibits a reduction in HBVviral load at end-of-treatment as compared to baseline. In someembodiments, a patient receiving treatment with interferon lambdamonotherapy exhibits a reduction in the level of HBsAg atend-of-treatment as compared to baseline. In some embodiments, a patientreceiving treatment with interferon lambda monotherapy exhibits improvedclearance of HBsAg antigen.

Example 11: Triple Therapy

This prophetic example describes treating HDV infection byadministration of interferon lambda in combination with lonafarnib andritonavir. Administration of pegylated interferon lambda in combinationwith lonafarnib and ritonavir provides efficacious therapy at lowerdoses and/or reduced dosing frequency.

A patient infected with HDV is administered pegylated interferon lambdaat 120 mcg QW or 180 mcg QW, in combination with one of the followinglonafarnib+ritonavir dosage combinations:

-   -   lonafarnib 50 mg BID+ritonavir 100 mg BID    -   lonafarnib 25 mg BID+ritonavir 100 mg BID    -   lonafarnib 75 mg BID+ritonavir 100 mg BID    -   lonafarnib 50 mg QD+ritonavir 100 mg QD    -   lonafarnib 75 mg QD+ritonavir 100 mg QD    -   lonafarnib 100 mg QD+ritonavir 100 mg QD    -   lonafarnib 50 mg QD+ritonavir 100 mg BID    -   lonafarnib 75 mg QD+ritonavir 100 mg BID    -   lonafarnib 100 mg QD+ritonavir 100 mg BID

During the course of the treatment the patient's HDV viral load isdetermined periodically. After 90 days of treatment the patient's viralload is reduced over baseline.

Example 12. Combination Regimens of Lonafarnib-Ritonavir Co-Therapy

This example demonstrates the efficacy and tolerability of variouscombination regimens of lonafarnib and ritonavir, with or withoutpegylated interferon-α, in patients known to be infected with HDV. 38patients were dosed as shown below in Table 15. The duration oftreatment was 12-24 weeks. On day 1 and day 28 of treatment, a 72 hourpharmacokinetics (PK) and pharmacodynamics (PD) evaluation wasperformed. Additionally, during the course of treatment biochemicalparameters and HDV RNA level (as measured by quantitative real-time PCR)were measured on days 1, 2, 3, 7, 14, and 28, and then every 4 weeksthereafter.

TABLE 15 Dosing regimen for lonafarnib-ritonavir cotherapy ± interferonAmount of Amount of Amount of Pegylated Number lonafarnib ritonavirinterferon-α of patients 100 mg BID 100 mg QD  — 3 100 mg BID  50 mg BID— 2 100 mg QD  100 mg QD  — 5 150 mg QD  100 mg QD  — 3  75 mg BID 100mg BID — 3  50 mg BID 100 mg BID — 6  25 mg BID 100 mg BID — 5  50 mgBID 100 mg BID 180 mcg QW 3  25 mg BID 100 mg BID 180 mcg QW 7

For all treatment groups, HDV RNA viral load was measured after 4 weeksand 8 weeks of treatment and compared to baseline HDV RNA virus load. Asshown in FIG. 15A, when HDV RNA viral load was measured after 4 weeks,comparable viral load decline was observed for patients receiving 25 mgBID or 50 mg BID lonafarnib in combination with 100 mg BID ritonavir,with or without pegylated interferon-α, as compared to patientsreceiving higher doses of lonafarnib in the lonafarnib-ritonavirco-therapy. As shown in FIG. 15B, when HDV RNA viral load was measuredafter 8 weeks, comparable viral load was observed for patients receiving25 mg BID or 50 BID lonafarnib in combination with 100 mg BID ritonavir,with or without pegylated interferon-α, as compared to patientsreceiving higher doses of lonafarnib in the lonafarnib-ritonavirco-therapy.

FIG. 16 shows that rapid declines in HDV viral levels were observed inpatients receiving 25 mg BID or 50 mg BID lonafarnib in combination with100 mg BID ritonavir, with or without pegylated interferon-α. Forpatients receiving 50 mg BID lonafarnib in combination with 100 mg BIDritonavir and patients receiving 50 mg BID lonafarnib in combinationwith 100 mg BID ritonavir and 180 mcg QW PEG IFN-α, the change in HDVRNA viral load after 8 weeks was comparable to the change in HDV RNAviral load after 48 weeks of treatment with 180 mcg QW PEG IFN-α incombination with tenofovir. Additionally, for a subset of patientsreceiving 50 mg BID lonafarnib in combination with 100 mg BID ritonavir,50 mg BID lonafarnib in combination with 100 mg BID ritonavir and 180mcg QW PEG IFN-α, or 25 mg BID lonafarnib in combination with 100 mg BIDritonavir and 180 mcg QW PEG IFN-α, HDV RNA viral negativity (clearance)was observed. See FIG. 17 and FIG. 18 .

For the group of patients receiving 50 mg BID lonafarnib in combinationwith 100 mg BID ritonavir, patients 2, 3, 4, and 5 were responsive totherapy, as defined by greater than or equal to a 0.5 log HDV RNAcopies/mL decline in quantitative serum HDV RNA levels from baseline tonadir during active treatment. See FIG. 17 (showing the time course ofthe log HDV IU/mL over 12 weeks of treatment).

For the group of patients receiving 50 mg BID lonafarnib in combinationwith 100 mg BID ritonavir and 180 mcg QW PEG IFN-α, patients 7 and 8were responsive to therapy, as defined by greater than or equal to a 0.5log HDV RNA copies/mL decline in quantitative serum HDV RNA levels frombaseline to nadir during active treatment. See FIG. 18 (showing the timecourse of the log HDV IU/mL over 32 weeks of treatment).

For the group of patients receiving 25 mg BID lonafarnib in combinationwith 100 mg BID ritonavir, patients 9, 10, 11, 12, 13, and 14 wereresponsive to therapy, as defined by greater than or equal to a 0.5 logHDV RNA copies/mL decline in quantitative serum HDV RNA levels frombaseline to nadir during active treatment. See FIG. 19 (showing the timecourse of the log HDV IU/mL over 8 weeks of treatment).

For the group of patients receiving 25 mg BID lonafarnib in combinationwith 100 mg BID ritonavir and 180 mcg QW PEG IFN-α, patients 15, 16, 17,19, and 20 were responsive to therapy, as defined by greater than orequal to a 0.5 log HDV RNA copies/mL decline in quantitative serum HDVRNA levels from baseline to nadir during active treatment. See FIG. 20(showing the time course of the log HDV IU/mL over 20 weeks oftreatment).

In addition, normalization of ALT values was observed for 65% ofpatients at week 12. As shown in FIG. 21 , 17 patients had elevated ALTvalues at baseline, but only 6 patients had elevated ALT values at week12. The upper limit of normal for ALT values was 45 for males and 34 forfemales.

Dosing regimens with lower dosages are also better tolerated, as shownin Table 16 below. The numbers in the table indicate the number ofpatients experiencing an adverse event. Mostly grade 1 gastrointestinalAEs were observed with the lower doses.

TABLE 16 N = 3 LNF 50 mg N = 4* N = 3* N = 5** N = 3 N = 3 N = 5 BID +RTV LNF 100 mg LNF 100 mg LNF 100 mg LNF 150 mg LNF 75 mg LNF 50 mg 100mg BID + BID + RTV BID + RTV QD + RTV QD + RTV BID + RTV BID + RTV PEGIFNα 100 mg QD 50 mg BID 100 mg QD 100 mg QD 100 mg BID 100 mg BID 180mcg QW Grade 1-2 3-4 1-2 3-4 1-2 3-4 1-2 3-4 1-2 3-4 1-2 3-4 1-2 3-4Nausea 1 4 2 2 2 1 Diarrhea 1 2 2 3 1 2 2 1 4 3 Fatigue 2 1 2 2 2 2 1 21 4 3 Anorexia 2 1 2 3 2 1 3 2 2 Wt loss 2 Vomiting 3 1 1 *1discontinuation **2 discontinuations

Example 13. Lonafarnib-Ritonavir Co-Therapy Duration Study

This example demonstrates the efficacy and tolerability of three dosesof lonafarnib (50 mg, 75 mg, and 100 mg) administered once daily, eachin combination with ritonavir 100 mg administered once daily for 12 or24 weeks. 21 patients with chronic HDV infection were randomized intoone of six treatment groups as summarized in Table 17 below:

TABLE 17 Number Months 1-3 Months 4-6 of patients Lonafarnib 100 mg QD +Lonafarnib 100 mg QD + 4 ritonavir 100 mg QD ritonavir 100 mg QDLonafarnib 75 mg QD + Lonafarnib 75 mg QD + 4 ritonavir 100 mgQDritonavir 100 mg QD Lonafarnib 50 mg QD + Lonafarnib 50 mg QD + 4ritonavir 100 mgQD ritonavir 100 mg QD Placebo Lonafarnib 100 mg QD + 3ritonavir 100 mg QD Placebo Lonafarnib 75 mg QD + 3 ritonavir 100 mg QDPlacebo Lonafarnib 50 mg QD + 3 ritonavir 100 mg QD

The lonafarnib/ritonavir co-therapy is expected to result in meanHDV-RNA declines of 2 log after 12 weeks of co-therapy. It isanticipated that doses of 50 mg QD lonafarnib in combination with 100 mgQD ritonavir, and 75 mg QD lonafarnib in combination with 100 mg QDritonavir will be tolerable to enable greater than 24 weeks of dosing.It is anticipated that the addition of an interferon (e.g., pegylatedinterferon alpha or pegylated interferon lambda) for greater than 24weeks may achieve HDV-RNA negativity in a subset of patients.

Example 14. Lonafarnib-Ritonavir Co-Therapy Dose Titration Study

This example demonstrates the efficacy, safety, and tolerability oflonafarnib and ritonavir co-therapy administered twice daily. 15patients (11 male) were enrolled in a 24-week open-label study thatincluded the option of dose escalation at the discretion of theinvestigator. The study was a Phase 2 study of 24 weeks of treatmentwith a dose-titration regimen of lonafarnib/ritonavir in patientschronically infected with HDV. Lonafarnib was administered starting at50 mg BID and escalating to 75 mg BID and then 100 mg BID as tolerated,in combination with ritonavir administered at 100 mg BID. The initialdose of lonafarnib (50 mg BID) and ritonavir (100 mg BID) was maintainedfor at least 4 weeks; subsequent dose escalation occurred at an intervalof no less than 2 weeks after patients had first received a particulardose.

At baseline (BL), the mean HDV RNA viral load for the patients was 6.53log₁₀ IU/mL (range 4.43-8.31 log₁₀ IU/mL). The mean serum ALT level was111 U/L (range 53-362 U/L). Liver stiffness (fibrosis) was also assessedby FibroScan®. Two patients were cirrhotic on biopsy. 11 patients werereceiving a nucleoside or nucleotide analogue (NUC) at BL.

By Week 8 of treatment, 10 of the 15 patients (66%) were able to bedose-escalated to 100 mg BID lonafarnib in combination with ritonavir.All patients exhibited declines in HDV RNA viral load, with a meandecline from BL to Week 8 of 1.87 log₁₀ IU/mL (range 0.88-3.13 log₁₀IU/mL). Three patients exhibited HBV DNA rebound associated with HDV RNAdecline, and two of the patients were started on treatment with theanti-HBV medication tenofovir. AE were mostly grade 1-2 intermittentdiarrhea; 3 patients had grade 3 AE (2 diarrhea; 1 asthenia), alltransient and non-recurring; no patients had a grade 4 AE. This datafrom 8 weeks treatment demonstrates that dose-escalation of lonafarnibin combination with ritonavir was feasible, and led to early decline inHDV RNA in all patients. HDV RNA decline was associated with a reboundof HBV DNA in patients not receiving a NUC, suggesting a suppressiveeffect of HDV on HBV replication. These data support the use of longerdurations of therapy.

A schematic of the dose titration regimen through 24 weeks of treatmentis shown in FIG. 22 . As shown in FIG. 22 , after 24 weeks of treatment,5 of the 15 patients (33%) maintained a dose of 100 mg BID lonafarnib incombination through Week 24 (EOT). The patients who maintained the doseof 100 mg BID lonafarnib in combination with ritonavir exhibited a meandecline in HDV RNA viral load from BL to Week 24 of 2.9 log₁₀ IU/mL. SeeFIG. 23 . Of these 5 patients, one patient (patient 3) achieved HDV-RNAnegativity at Week 24, and one patient reduced HDV-RNA viral load to 32IU/mL (i.e., 1.5 log₁₀ IU/mL) at Week 24 (the lower limit of detectionis 14 IU/mL). See FIG. 24 .

Of the 10 patients who were dose-escalated to 100 mg BID lonafarnib incombination with ritonavir by Week 8 of treatment, 5 patients werede-escalated to a lower dose. See FIG. 23 . These patients exhibited alower decline in HDV-RNA viral load than patients who maintained thedose of 100 mg BID lonafarnib in combination with ritonavir through Week24. The remaining 5 patients, who received either a “partial” doseescalation (patient was not successfully escalated to 100 mg lonafarnibBID) or no dose escalation from 50 mg BID lonafarnib in combination withritonavir, exhibited a mean decline in HDV RNA viral load from BL toWeek 24 of 2.3 log₁₀ IU/mL.

Normalization of ALT values was observed for 53% of patients at week 24.As shown in FIG. 25 , all 15 patients had elevated ALT values atbaseline, but only 7 patients had elevated ALT values at week 24.Patients experienced predominantly grade 1-2 GI adverse events, as shownin Table 18 below. Table 18 shows the number of patients experiencing aparticular grade of GI AE at least once during the 24-week study. Themost common AE was intermittent diarrhea, grades 1-2. No grade 4 AEswere observed.

TABLE 18 Adverse Event Grade 1 Grade 2 Grade 3 Grade 4 Nausea  7 6 0 0Diarrhea 15 7 2 0 Asthenia  3 3 1 0 Anorexia  7 6 0 0 Weight Loss  8 5 00 Vomiting  4 1 0 0

Example 15. Induction of Post-Treatment ALT Flares with LonafarnibTherapy

This example describes post-treatment ALT flares and their outcomes inpatients treated with 12 or 24 weeks of lonafarnib in various treatmentregimens, such as the regimens described in Example 12 above.Twenty-seven (27) patients were analyzed who had detectable HDV RNAafter receiving lonafarnib for 12 or 24 weeks at various doses oflonafarnib, in some cases in combination with ritonavir and/or pegylatedinterferon alpha. A post-treatment ALT flare was defined as elevation ofALT to >2× baseline ALT level.

To date, 5 of 27 (18.5%) patients studied have experiencedpost-treatment ALT flares. These post-treatment flares (median ALT 190U/L, range 110-1355 U/L) led to ALT normalization and HDV RNA negativitywithin 12-24 weeks. These 5 patients came from the following lonafarnibtreatment cohorts:

-   -   Patient A-001-5. 200 mg BID lonafarnib administered for 12 weeks        (FIG. 26 );    -   Patient A-001-1. 300 mg BID lonafarnib administered for 12 weeks        (FIG. 27 );    -   Patient A-002-3. 100 mg BID lonafarnib in combination with 50 mg        BID ritonavir administered for 12 weeks (FIG. 28 );    -   Patient A-002-14. 75 mg BID lonafarnib in combination with 100        mg BID ritonavir administered for 12 weeks, followed by addition        of pegylated interferon alpha for 12 weeks (FIG. 29 ); and    -   Patient A-002-23. 50 mg BID lonafarnib in combination with 100        mg BID ritonavir administered for 24 weeks (FIG. 30 ).

One patient (patient A-002-3) cleared HBV DNA and subsequently clearedHBsAg. See FIG. 28 . Two other patients (patient A-001-5 and patientA-002-23) exhibited declines in HBV DNA of 2 logs or greater. See FIG.26 and FIG. 30 . All 5 patients exhibited rapid initial declines of HDVRNA upon initiation of lonafarnib treatment; these rapid initialdeclines were eventually followed by more gradual rises upon therapyassociated with decreased lonafarnib exposure (due to dose reductions orexcessive GI side effects).

As illustrated in FIG. 26 in Patient A-001-5, a 12-week course oftreatment with lonafarnib (200 mg BID) resulted in an ALT flare and asuppression of HDV RNA to undetectable levels. A subsequent rise in HDVviral load (at about week 50) was suppressed by a second course oftreatment with lonafarnib (50 mg BID) and ritonavir (100 mg BID). Asshown in FIG. 26 , HDV become undetectable in this patient and thepatient remained apparently virus-free when measured at 132 weeks.Surprisingly, HBV VL (i.e., HBV DNA level) was also suppressed from abaseline of about 4 log IU/mL to approximately 1.5 log IU/mL (i.e.,below than the LOQ). See FIG. 26 .

As illustrated in FIG. 27 in Patient A-001-1, a 12-week course oftreatment with lonafarnib (300 mg BID) resulted in an ALT flare and asuppression of HDV RNA below about 3 logs (weeks 30-54). A rise in HDVVL was observed (e.g., week 78), and was suppressed by a second courseof treatment with low dose lonafarnib therapy (50 mg BID) and ritonavir(100 mg BID). The transient rise in HBV DNA level was also suppressedfollowing the ALT flare. The patient remained apparently virus-free whenmeasured at 125 weeks.

As illustrated in FIG. 28 in Patient A-002-3, treatment with lonafarnib(100 mg BID) and ritonavir (50 mg BID) for about 10 weeks followed bylonafarnib (150 mg QD) and ritonavir (50 mg BID) for 2 weeks resulted inan ALT flare. HDV RNA and HBV DNA levels dropped to undetectable levels.The patient remained apparently virus-free when measured at 95 weeks.

As illustrated in FIG. 29 in Patient A-002-14, a 24-week course oftreatment with lonafarnib, ritonavir and pegylated interferon alpha asshown in the figure resulted in an ALT flare and the suppression of HDVRNA VL from greater than 6 log IU/mL to below the limit of quantitationfor the assay (i.e., less than 3.2 log IU/mL).

As illustrated in FIG. 30 in Patient A-002-23, a 24-week course oftreatment with lonafarnib (50 mg BID) and ritonavir (100 mg BID)resulted in an ALT flare and a suppression of HDV RNA to approximately 0log IU/mL.

The data presented herein suggest that a short course of lonafarnib maycontribute to an effective reset and activation of the immune reactivityin chronic delta hepatitis, which surprisingly in some cases may spreadto HBV. Thus, there appear to be at least two pathways for achieving HDVnegativity with lonafarnib therapy: first, lonafarnib-inducedprogressive suppression to HDV negativity with ALT normalization duringthe course of treatment (a more classical anti-viral approach), andsecond, lonafarnib-induced anti-HDV ALT flares that occur post-treatmentand result in HDV clearance.

Example 16. Preparation of Lonafarnib-Ritonavir-Copolymer Compositions

(A) 1:1:2 Co-Precipitate

5.0 gram of ritonavir, 5.47 gram of lonafarnib, and 10.0 gram ofPovidone K30 were dissolved in 600 mL of dichloromethane by stirring atroom temperature. The solution was spray dried using a Model GB22 YamatoLab Spray Dryer with the following operating parameters: internal nozzlediameter 711 μm; pump rate 12-14 mL/min; inlet temperature 60° C.;outlet temperature NMT 45° C.; atomization air pressure 0.15 MPa and airflow 0.5 m³/min. For 20.47 g of solids in the spray solution, 15.9 gwere collected in the receiving flask for a yield of 77%. The totalsolids in the spray solution was 3% (w/v).

(B) 1:2:3 Co-Precipitate

6.5 gram of the ritonavir-lonafarnib-providone (1:1:2) co-precipitate of(A) (which corresponds to 1.6 gram of ritonavir, 1.6 gram lonafarnib,and 3.3 gram of povidone K30), an additional 1.6 gram of ritonavir (fora total quantity of ritonavir of 3.2 gram), and an additional 1.5 gramof povidone K30 (for a total quantity of povidone K30 of 4.8 gram) weredissolved in 300 mL of dichloromethane by stirring at room temperature.The solution was spray dried using a Model GB22 Yamato Lab Spray Dryerwith the following operating parameters: internal nozzle diameter 711μm; pump rate 12-14 mL/min; inlet temperature 60° C.; outlet temperatureNMT 45° C.; atomization air pressure 0.15 MPa and air flow 0.5 m³/min.For 9.6 g of solids in the spray solution, 5.6 g were collected in thereceiving flask for a yield of 58%. The total solids in the spraysolution was 3% (w/v).

(C) 1:1:5 Co-Precipitate

7.5 gram of the ritonavir-lonafarnib-providone (1:1:2) co-precipitate of(A) (which corresponds to 1.9 gram of ritonavir, 1.9 gram lonafarnib,and 3.8 gram of povidone K30), and an additional 5.0 gram of povidoneK30 (for a total quantity of povidone K30 of 8.8 gram) were dissolved in390 mL of dichloromethane by stirring at room temperature. The solutionwas spray dried using a Model GB22 Yamato Lab Spray Dryer with thefollowing operating parameters: internal nozzle diameter 711 μm; pumprate 12-14 mL/min; inlet temperature 60° C.; outlet temperature NMT 45°C.; atomization air pressure 0.15 MPa and air flow 0.5 m³/min. For 12.5g of solids in the spray solution, 8.8 g were collected in the receivingflask for a yield of 70%. The total solids in the spray solution was 3%(w/v).

(D) 1:1:2 Co-Precipitate with HPMC Polymer

2.5 gram of ritonavir, 2.61 gram of lonafarnib, and 5.0 gram ofhydroxymethylcellulose (HPMC) were dissolved in 340 mL ofdichloromethane by stirring at room temperature. The solution was spraydried using a Model GB22 Yamato Lab Spray Dryer with the followingoperating parameters: internal nozzle diameter 711 μm; pump rate 12-14mL/min; inlet temperature 60° C.; outlet temperature NMT 45° C.;atomization air pressure 0.15 MPa and air flow 0.5 m³/min. For 10.1 g ofsolids in the spray solution, 7.2 g were collected in the receivingflask for a yield of 71%. The total solids in the spray solution was 3%(w/v).

Analysis of Lonafarnib-Ritonavir-Copolymer Compositions

The amorphous state of each co-precipitate of (A)-(D) was verified byX-ray powder diffraction (XRPD). The diffraction pattern was verified byX-ray diffraction using a Bruker D2 Phaser X-ray diffractometer withLynxeye detector, Cu Kα radiation (λ=1.5406 Å). Acquisition was doneover a range of 5-55° 20, increment of 0.05° 2θ, 1.0 s step time and 0.6mm opening slit and a 2.5 mm detector windows. The samples were analyzedusing a low volume sample holder and kept under a constant rotation of15 rpm during the analysis. FIG. 31 is a powder X-ray pattern of theamorphous 1:1:2, 1:2:3, and 1:1:5 ritonavir-lonafarnib-co-polymerco-precipitates with povidone as the co-polymer. Consistent with thecharacteristic of amorphous solid form, the amorphous 1:1:2, 1:2:3, and1:1:5 co-precipitates do not exhibit crystalline diffraction peaks. Theamorphous 1:1:2 co-precipitate with HPMC also does not exhibitcrystalline diffraction peaks (data not shown).

Residual solvent from spray-dried material was verified bythermogravimetric analysis (TGA). The analysis was performed using a TAInstrument Q50 thermogravimetric analyzer at scanning speed of 10° C.min′ over a temperature range of 25 to 200° C. The samples were heatedin a platinum open pan under nitrogen purge (60 mL min⁻¹).

FIG. 32A illustrates the sample weight (in percent of original weight)as a function of temperature. This material exhibited distinctweight-loss steps. The first step (weight loss 4.8-5.6%) at temperaturesbetween 25 and 100° C. corresponds to loss of volatile compounds (waterand dichloromethane) followed by material decomposition initiated atapproximately 180° C. Identification and quantification of residualsolvents using more sophisticated techniques such gas chromatographyshould be employed to ensure compliance with ICH Q3C guidelines.

FIG. 32B compares samples with similar API (active pharmaceuticalingredient) compositions but different polymers, a 1:1:2ritonavir-lonafarnib-povidone containing sample and a 1:1:2ritonavir-lonafarnib-HPMC containing sample. As shown in FIG. 23B, theHPMC-containing sample contains 1.7% of volatiles, much lower comparedto the povidone-containing sample at 4.8%. This difference is likelylinked to higher hygroscopicity and/or dichloromethane affinity ofpovidone versus HPMC.

Example 17. Exemplary Co-Therapy Dosages

For illustration and not limitation, this example provides exemplarydoses for lonafarnib-ritonavir co-therapy and for lonafarnib-interferonlambda co-therapy. For lonafarnib-ritonavir co-therapy, exemplary dosesinclude the following combinations (with reference to Table 19): L1+(R1or R2 or R3), where L1 and R are from the same row.

TABLE 19 L1 R1 R2 R3  25 BID 50 BID 75 BID 100 BID  50 BID 50 BID 75 BID100 BID  75 BID 50 BID 75 BID 100 BID 100 BID 50 BID 75 BID 100 BID  50QD 50 QD  75 QD  100 QD   75 QD 50 QD  75 QD  100 QD  100 QD 50 QD  75QD  100 QD   50 QD 50 BID 75 BID 100 BID  75 QD 50 BID 75 BID 100 BID100 QD 50 BID 75 BID 100 BID

For lonafarnib-interferon lambda co-therapy, exemplary doses, forillustration and not limitation, include the following combinations(with reference to Table 20):

TABLE 20 Lonafarnib dose Interferon lambda dose  50 mg BID 120 mcg QW 75 mg BID 120 mcg QW 100 mg BID 120 mcg QW

All publications and patents cited in this specification are hereinincorporated by reference as if each individual publication or patentwere specifically and individually indicated to be incorporated byreference and are incorporated herein by reference to disclose anddescribe the methods and/or materials in connection with which thepublications are cited.

It should be understood that although the present invention has beenspecifically disclosed by certain aspects, embodiments, and optionalfeatures, modification, improvement and variation of such aspects,embodiments, and optional features can be resorted to by those skilledin the art, and that such modifications, improvements and variations areconsidered to be within the scope of this disclosure.

The inventions have been described broadly and generically herein. Eachof the narrower species and subgeneric groupings falling within thegeneric disclosure also form part of the invention. In addition, wherefeatures or aspects of the invention are described in terms of Markushgroups, those skilled in the art will recognize that the invention isalso thereby described in terms of any individual member or subgroup ofmembers of the Markush group.

What is claimed is:
 1. A method of reducing hepatitis delta virus (HDV)viral load in a human patient with a chronic HDV infection, comprisingadministering a lonafarnib-ritonavir co-therapy to the human patient,wherein lonafarnib is administered at least once per day.
 2. The methodof claim 1, wherein ritonavir is administered at least once per day. 3.The method of claim 1, wherein the co-therapy comprises administrationof lonafarnib at a total daily dose of 100 mg.
 4. The method of claim 1,wherein the lonafarnib is administered at a dose of 25 mg BID to 100 mgBID and the ritonavir is administered at a dose of 50 mg BID to 100 mgBID or 100 mg QD.
 5. The method of claim 1, wherein lonafarnib isadministered at a dose of 50 mg QD to 150 mg QD and ritonavir isadministered at a dose of 100 mg QD.
 6. The method of claim 1, whereinat least one of lonafarnib or ritonavir is administered orally.
 7. Themethod of claim 1, wherein lonafarnib and ritonavir are administeredtogether in a single unit dose form.
 8. The method of claim 1, whereinlonafarnib and ritonavir are administered as separate unit dose forms.9. The method of claim 1, wherein the human patient is treated with thelonafarnib-ritonavir co-therapy for at least 2 weeks, at least 2 months,at least 3 months, at least 4 months, at least 5 months, at least 6months, or at least 1 year.
 10. The method of claim 1, whereinlonafarnib and ritonavir are administered in amounts that result inserum lonafarnib concentrations greater than 2,000 ng/ml or greater than4,000 ng/ml, or in a range from 3,500 ng/ml to about 7,500 ng/ml. 11.The method of claim 1, wherein the human patient has a baseline viralload of at least 10⁴ HDV RNA copies per mL serum before the initiationof treatment.
 12. The method of claim 11, wherein thelonafarnib-ritonavir co-therapy results in a reduction of viral loadfrom at least 10⁵ RNA copies per mL to less than 10² HDV RNA copies permL serum.
 13. The method of claim 11, wherein the lonafarnib-ritonavirco-therapy results in a reduction of viral load from at least 10⁷ RNAcopies per mL to less than 10⁵ HDV RNA copies per mL serum.
 14. Themethod of claim 1, wherein the lonafarnib-ritonavir co-therapy resultsin a reduction of HDV viral load of at least 1.5 log HDV RNA copies/mLserum.
 15. The method of claim 1, wherein the lonafarnib-ritonavirco-therapy results in a reduction of HDV viral load to an undetectablelevel.
 16. The method of claim 1, wherein the human patient experiencesa sustained reduction in HDV RNA levels for a least one month.
 17. Themethod of claim 1, wherein after the human patient is determined to havea viral load of less than 10² HDV RNA copies per mL serum, treatmentwith lonafarnib-ritonavir co-therapy continues for at least 30 days. 18.The method of claim 1, wherein the human patient experiences a decreasein HDV RNA levels of at least 1 log before experiencing an increase inHDV RNA levels of at least 50% or more from the nadir during treatment.19. The method of claim 1, wherein the human patient is also infectedwith hepatitis B virus (HBV) and experiences a transient increase of atleast 3 log in HBV viral load.
 20. The method of claim 1, wherein thehuman patient has improved liver function during or after treatment. 21.The method of claim 1, wherein during or after treatment the humanpatient has improved liver biopsy as assessed by one or more of thefollowing: histological staining, immunohistochemical staining, andfibrosis grading.
 22. The method of claim 1, wherein the human patienthas a delay in the need for a liver transplant for at least 3 months.23. The method of claim 1, wherein the human patient experiences anaminotransferase (ALT) flare.
 24. The method of claim 1, wherein thehuman patient has a baseline ALT level before initiation of treatmentthat is at least two-fold higher than upper limit of normal (ULN). 25.The method of claim 1, wherein the human patient is treated for at least24 weeks, and wherein the method results in a normalization of the humanpatient's alanine ATL level following an ATL flare.
 26. The method ofclaim 23, wherein the lonafarnib-ritonavir co-therapy is discontinuedwithin 25 weeks following the ALT flare.
 27. The method of claim 1,wherein the lonafarnib-ritonavir co-therapy comprises administeringlonafarnib QD or BID at a first dose for a first treatment period andadministering lonafarnib QD or BID at a second dose for a secondtreatment period subsequent to the first treatment period.
 28. Themethod of claim 27, wherein the first dose is greater than the seconddose.
 29. The method of claim 27, wherein the first dose is less thanthe second dose.
 30. The method of claim 27, wherein the first dose andthe second dose are the same.
 31. The method of claim 27, wherein thefirst treatment period and the second treatment period are differentlengths of time.
 32. The method of claim 1, wherein administration ofthe lonafarnib-ritonavir co-therapy to the human patient is ceased whenHDV viral load is undetectable.
 33. The method of claim 32, whereinadministration of the lonafarnib-ritonavir co-therapy to the humanpatient is resumed when HDV viral load is detectable again in the humanpatient.
 34. The method of claim 1, further comprising administeringinterferon alpha or interferon lambda to the human patient.
 35. Themethod of claim 34, wherein the interferon alpha or the interferonlambda is administered weekly at a dose of 120 micrograms per week or180 micrograms per week.